Inspection Reports for MorningStar Assisted Living & Memory Care of Santa Fe
NM
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than New Mexico average
New Mexico average: 7.1 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
91 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Sep 25, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to reporting of incidents and compliance with assisted living facility regulations.
Findings
The facility failed to report incidents of suspected abuse involving unwitnessed falls with injury for three residents within required timeframes and did not conduct timely internal investigations. Additionally, the facility failed to provide a safe living environment, including an employee consuming alcohol on premises, and kitchen staff not wearing hairnets while serving food.
Complaint Details
Complaint intake NM was investigated with deficiencies cited. Complaint intake NM and another intake were investigated with no deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Failure to report incidents of suspected abuse involving unwitnessed falls with injury within 24 hours and failure to conduct internal investigations within 5 business days. |
| Failure to provide a safe living environment, including an employee consuming alcohol during work hours. |
| Failure to ensure kitchen staff wore hairnets or caps while serving food, risking food contamination. |
Report Facts
Resident census: 91
Residents involved in incident reporting deficiency: 3
Residents affected by safe living environment deficiency: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MC Care Manager #1 | Memory Care Manager | Observed consuming alcoholic drink during work hours in employee breakroom. |
| MC Care Manager #2 | Memory Care Manager | Confirmed observation of MC Care Manager #1 consuming alcohol. |
| Executive Chef | Executive Chef | Confirmed kitchen staff were not wearing hairnets and stated no hairnet supply was available. |
| Interim Administrator | Interim Administrator | Confirmed incidents were not reported timely and internal investigations were not conducted. |
| Regional Vice President of Wellness | Regional Vice President of Wellness | Confirmed incident involving resident transported to hospital should have been reported. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Jan 25, 2025
Visit Reason
The inspection was conducted as a complaint survey on 01/25/25 to investigate a complaint intake related to medication administration at an assisted living facility.
Findings
The facility failed to ensure that medication errors for Resident #3 were properly reported and documented with the prescriber's response in the resident's record, which could likely cause harm if wrong medication was administered and not documented or reported.
Complaint Details
Complaint intake was investigated with deficiency cited related to medication administration errors for Resident #3.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medication errors were reported and documented with prescriber's response for Resident #3. |
Report Facts
Resident Census: 80
Dates of medication errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Martinez | Executive Director | Confirmed during interview that medication errors were not documented in Resident #3's file. |
Inspection Report
Re-Inspection
Deficiencies: 2
Nov 23, 2022
Visit Reason
This document is a revisit survey conducted to assess compliance with state requirements for assisted living facilities providing hospice and memory care services, specifically focusing on training requirements for staff.
Findings
The facility was found deficient in ensuring that Direct Care Staff (DCS) completed the required annual training hours for palliative/hospice care and dementia/Alzheimer's disease care. These deficiencies were repeat findings from previous surveys.
Deficiencies (2)
| Description |
|---|
| Direct Care Staff failed to complete the minimum six (6) hours per year of palliative/hospice care training. |
| Direct Care Staff failed to complete the minimum twelve (12) hours per year of training related to Dementia or Alzheimer's disease. |
Report Facts
Residents affected: 7
Residents affected: 23
Training hours required: 6
Training hours completed: 5
Training hours completed: 5.5
Training hours required: 12
Training hours completed: 3
Training hours completed: 4
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 7
Nov 23, 2022
Visit Reason
Complaint survey completed on 11/23/22 in accordance with New Mexico regulations for Assisted Living Facilities for Adults, triggered by multiple complaint intake IDs.
Findings
The facility was found deficient in multiple areas including resident records, resident evaluations, individualized service plans, incident reporting, custodial drug permits, medication administration, and nutrition. Several residents' records lacked required documentation and timely evaluations. Incident reports were not submitted timely or completely. Medication errors and missing documentation were noted. Nutrition and food safety standards were not fully met.
Complaint Details
Multiple complaint intake IDs were reviewed; some were substantiated with deficiencies cited, others were unsubstantiated. The complaint survey identified failures in documentation, incident reporting, medication administration, and resident care.
Deficiencies (7)
| Description |
|---|
| Failure to maintain complete progress notes for health services provided by contracted agencies for residents. |
| Resident evaluations not completed within required timeframes or reviewed by licensed personnel. |
| Individualized Service Plans (ISPs) not reviewed or revised by licensed personnel as required. |
| Failure to report incidents to Licensing Authority within required timeframes and complete investigations. |
| Custodial drug permits and medication administration records incomplete or missing required documentation. |
| Medication errors not reported to physician or documented properly. |
| Nutrition deficiencies including replacement of trash receptacles with lids and food safety practices. |
Report Facts
Residents reviewed: 7
Residents affected: 50
Incident report days: 5
Medication administration review period: 3
Meal service frequency: 3
Trash cans observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Martinez | Executive Director | Named as provider/supplier representative signing the report. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Jul 27, 2021
Visit Reason
Complaint survey completed on 07/27/21 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. The visit was triggered by complaint #NM 52182 which was substantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including resident records, resident evaluations, individual service plans, incident reporting, resident rights, nutrition, hospice care, and memory care units. Deficiencies included failure to maintain records onsite, incomplete resident evaluations, lack of signatures on service plans, failure to report incidents timely, and inadequate staff training on dementia and hospice care.
Complaint Details
Complaint #NM 52182 was substantiated with deficiencies cited related to resident records, evaluations, incident reporting, and care planning.
Deficiencies (7)
| Description |
|---|
| Failure to ensure resident records were maintained onsite and available within 24 hours of request. |
| Failure to ensure resident evaluations contained accurate nutritional status and risk factors. |
| Failure to ensure individual service plans included goals, outcomes, and signatures. |
| Failure to report incidents to Licensing Authority within 24 hours or next business day. |
| Failure to protect resident rights including privacy, dignity, and participation in care planning. |
| Failure to provide planned and nutritionally balanced meals and maintain proper food safety standards. |
| Failure to provide required training for staff on hospice and dementia care. |
Report Facts
Weight loss: 57
Training hours: 6
Training hours: 12
Training hours: 1.5
Training hours: 0
Training hours: 10.5
Training hours: 0
Inspection Report
Routine
Deficiencies: 0
Oct 21, 2020
Visit Reason
An onsite surveillance was conducted related to Covid 19 infection prevention and control.
Findings
The report documents an onsite surveillance visit focused on Covid 19 infection prevention and control measures.
Inspection Report
Initial Licensing
Deficiencies: 0
Oct 21, 2020
Visit Reason
Initial/Complaint survey conducted to assess compliance with state regulations for assisted living facilities.
Findings
No deficiencies were cited during the survey. Two complaint intakes (NM 44344 and NM 43932) were investigated and found unsubstantiated without deficiencies.
Complaint Details
Complaint Intake NM 44344 unsubstantiated without deficiencies. Complaint Intake NM 43932 unsubstantiated without deficiencies.
Inspection Report
Routine
Deficiencies: 0
Aug 13, 2020
Visit Reason
An Offsite Surveillance review was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance review.
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 30, 2020
Visit Reason
The inspection was conducted to assess compliance with the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the survey completed on 06/30/2020.
Inspection Report
Routine
Deficiencies: 0
May 22, 2020
Visit Reason
An Offsite Surveillance review was completed related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the COVID-19 infection prevention and control surveillance review.
Inspection Report
Routine
Deficiencies: 0
Apr 29, 2020
Visit Reason
Offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Apr 2, 2020
Visit Reason
An offsite surveillance review was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance review.
Inspection Report
Routine
Deficiencies: 0
Mar 17, 2020
Visit Reason
An onsite surveillance review was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the COVID-19 infection prevention and control surveillance review.
Inspection Report
Original Licensing
Deficiencies: 2
Nov 26, 2019
Visit Reason
An initial life safety code survey was conducted at the facility per the provider's request.
Findings
The facility was found in substantial compliance with the Life Safety Code portion of the New Mexico State Requirements for Assisted Living Facilities for Adults 7.8.2 NMAC. Temporary licensure was recommended with conditions related to a fire alarm system trouble and water damage in resident room #232.
Deficiencies (2)
| Description |
|---|
| The fire alarm system was in trouble and supervisory mode due to a failed sprinkler piping coupler that saturated the smoke detector in resident room #232; the smoke detector was being replaced. |
| The drywall ceiling in resident room #232 had water damage from the failed sprinkler piping coupler; the room was not to be occupied until repaired. |
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