Inspection Reports for
Santa Fe Care Center
635 HARKLE ROAD, SANTA FE, NM, 87505
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
97% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident safety, including fall prevention measures and pharmacy medication regimen reviews.
Findings
The facility failed to ensure fall mats were present as ordered for two residents at risk of falls, and failed to complete required monthly pharmacy medication reviews for five residents, resulting in potential risks to resident safety and health.
Deficiencies (2)
Failure to provide fall mats as ordered by a physician for residents at high risk of falls.
Failure to complete required monthly pharmacy medication reviews and to carry out approved pharmacy recommendations for multiple residents.
Report Facts
Residents reviewed for falls: 2
Residents reviewed for pharmacy reviews: 7
Residents with missed pharmacy reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed fall mats should be present and pharmacy reviews were missed |
| Director of Rehab | Director of Rehab | Confirmed fall mat should be present for resident #24 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed fall mat was not present for resident #24 |
| Scheduler | Scheduler | Confirmed fall mat was not present for resident #71 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was conducted to identify deficiencies related to the development and implementation of a complete, person-centered care plan for residents, specifically focusing on one resident's care plan accuracy and compliance.
Findings
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for one resident, resulting in a discrepancy between the care plan and actual practice regarding the storage of the resident's beer. The care plan stated the beer should be kept in a locked refrigerator, but the resident had a cooler with beer in his room.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed confirming resident's beer allowance and care plan details. | |
| Administrator | Interviewed confirming resident's beer storage practice and care plan discrepancy. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 25, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to notify providers and Director of Nursing of a resident's injury, failure to report and investigate an injury of unknown origin, failure to update care plans, failure to provide adequate activities of daily living assistance, failure to provide proper wound care, and incomplete resident medical records.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to notify providers and the Director of Nursing about a resident's injury, failed to conduct a complete investigation of the injury, and failed to provide adequate care and documentation for multiple residents.
Findings
The facility failed to notify providers and the Director of Nursing about a significant injury to a resident's left forearm, failed to properly investigate the injury, failed to update the resident's care plan to include anticoagulant use, failed to provide adequate toenail care, and failed to provide appropriate wound care and reassessment leading to worsening injury and hospitalization. Additionally, the facility's medical records for three residents were incomplete or inaccurate, lacking critical information such as weight-bearing status, hospital transfers, and behavioral incidents.
Deficiencies (6)
Failed to notify providers and Director of Nursing of a resident's significant left forearm injury resulting in worsened condition and hospitalization.
Failed to report and investigate an injury of unknown origin for a resident, resulting in incomplete investigation.
Failed to update the care plan to include anticoagulant use for a resident.
Failed to provide adequate activities of daily living assistance for toenail care.
Failed to provide proper wound care and reassessment for a resident's left forearm laceration, resulting in worsening injury and hospitalization.
Failed to maintain complete and accurate medical records for three residents, including failure to document weight-bearing status, hospital transfers, and behavioral incidents.
Report Facts
Residents reviewed for injury: 3
Residents reviewed for medical record accuracy: 3
Wound measurement: 4
Wound measurement: 1.5
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Noted resident #4's injury, applied initial bandage, failed to ensure reassessment and proper communication |
| RN #2 | Registered Nurse | Day shift nurse on 09/09/24 who did not reassess resident #4's injury or communicate properly |
| Director of Nursing | Director of Nursing (DON) | Expected notification and reassessment of resident #4's injury, confirmed failures in investigation and care |
| Nurse Practitioner | Nurse Practitioner (NP) | Confirmed expectation to be notified immediately of significant injuries like resident #4's |
| CNA #1 | Certified Nursing Assistant | Assisted resident #4 on night shift when injury occurred, observed injury and bandaging |
| CNA #2 | Certified Nursing Assistant | Observed resident #4's injury during day shift, reported to RN #2 |
| Wound Care Nurse | Wound Care Nurse (WCN) | Notified late about resident #4's injury, confirmed lack of communication |
| Administrator | Administrator (ADM) | Confirmed failure to investigate resident #4's injury and lack of documentation for resident #3's behaviors |
| Social Services Coordinator | Social Services Coordinator (SSC) | Sent referral documentation for resident #1, confirmed missing weight-bearing status |
Inspection Report
Routine
Deficiencies: 14
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, therapy services, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to provide written documentation of Medicare beneficiary notices, incomplete and inaccurate Minimum Data Set (MDS) assessments, missing care plans for specific resident needs, medication administration errors, failure to conduct ordered therapy evaluations, inadequate infection prevention and control practices including improper sanitization of glucometers and lack of enhanced barrier precautions, and lack of a qualified infection preventionist with specialized training.
Deficiencies (14)
Failed to have written documentation of Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) for one resident.
Failed to complete a Significant Change MDS within 14 days for one resident receiving hospice services.
Failed to complete a quarterly MDS assessment for one resident, overdue by 25 days.
Failed to accurately code MDS for hospice status and insulin use for three residents.
Failed to develop comprehensive care plans for dialysis with central venous catheter, oxygen use, and PTSD for three residents.
Failed to ensure medication orders included proper dosage and administered medications as ordered for three residents.
Failed to assess and intervene for gradual weight loss in one resident.
Failed to ensure oxygen concentrators had clean or any filters on inlet for five residents, increasing infection risk.
Failed to ensure blood pressure was monitored prior to administration of lisinopril and to withhold medication when systolic BP was less than 100 for one resident.
Medication error rate of 20% observed with errors in Lidoderm patch application/removal, levothyroxine refusal, and Vitamin B-12 dosage.
Failed to conduct ordered physical and occupational therapy evaluations for one resident.
Failed to sanitize glucometers between uses and failed to implement enhanced barrier precautions for residents with indwelling devices or wounds.
Failed to update infection control policies annually and lacked documentation of water safety management program monitoring.
Failed to designate a qualified infection preventionist with specialized training in infection prevention and control.
Report Facts
Sample residents reviewed: 20
Medication error rate: 20
Weight loss percentage: 7.5
Blood pressure monitoring days missed: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS1 | Minimum Data Set Coordinator / Infection Preventionist | Named as Infection Preventionist without completed specialized training |
| LPN3 | Licensed Practical Nurse | Named in medication administration errors and oxygen filter cleaning observations |
| LPN5 | Licensed Practical Nurse | Named in medication administration errors and lack of knowledge of enhanced barrier precautions |
| DON | Director of Nursing | Named in interviews regarding expectations for MDS accuracy, medication administration, oxygen equipment, and infection control |
| Administrator | Facility Administrator | Named in interviews regarding facility policies, infection control, and staff education |
| RN1 | Registered Nurse | Named in observations and interviews regarding glucometer sanitization |
| LPN2 | Licensed Practical Nurse | Named in observations and interviews regarding glucometer sanitization and lack of enhanced barrier precautions knowledge |
| Central Supply Staff | Central Supply Staff | Named in interviews regarding oxygen filter cleaning responsibilities |
| RD | Registered Dietician | Named in interviews regarding nutritional assessments and interventions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically regarding updating and revising care plans for residents with unwitnessed injuries.
Findings
The facility failed to revise and update the care plan for one resident with unwitnessed injuries, specifically not including total assistance for wheelchair use, which may result in inadequate care to meet the resident's needs.
Deficiencies (1)
Failed to revise and update the care plan for a resident with unwitnessed injuries to include total assistance for wheelchair use.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Interviewed regarding resident bruises and care plan deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify providers or emergency contacts of residents' changes in condition, failure to update care plans, delays in sending residents to the emergency room, inadequate wound care, insufficient nursing staff for safe resident transfers, and inaccurate medical record documentation.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify providers or emergency contacts of changes in condition, failure to update care plans, delays in emergency room transfers, inadequate wound care, insufficient staffing for safe transfers, and inaccurate medical record documentation.
Findings
The facility was found deficient in multiple areas including failure to notify providers or emergency contacts about residents' changes in condition, failure to update care plans for wounds, delays in sending residents to the emergency room as ordered, inadequate wound care treatment and communication, insufficient staffing leading to unsafe resident transfers, and incomplete or inaccurate medical record documentation.
Deficiencies (7)
Failed to notify provider or emergency contact for resident with change of condition.
Failed to update care plans to include current wounds and wound care for residents.
Delayed sending resident to emergency room contrary to physician orders.
Failed to provide timely treatment and care for resident with difficulty swallowing, lethargy, respiratory distress, and hypoxia.
Failed to provide wound care treatment and communicate new wounds for residents.
Failed to provide sufficient nursing staff to safely transfer residents requiring two staff members.
Failed to maintain accurate medical records including documentation of anti-embolic stocking use and daily progress notes for residents sent to emergency room.
Report Facts
Residents requiring two staff for transfers: 11
Residents affected by staffing deficiency: 11
Residents reviewed for care plan deficiencies: 2
Residents reviewed for notification failure: 1
Residents reviewed for wound care deficiencies: 2
Residents reviewed for medical record inaccuracies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding failure to notify provider and documentation issues. |
| MD #1 | Medical Doctor | Interviewed confirming expectations for notification and wound care orders. |
| DON | Director of Nursing | Confirmed multiple deficiencies including notification, care planning, wound care, staffing, and documentation. |
| ADON | Assistant Director of Nursing | Confirmed wound care treatment order deficiencies. |
| RN #1 | Registered Nurse | Interviewed about documentation and resident condition. |
| WCN | Wound Care Nurse | Confirmed delay in wound care orders and treatment. |
| CNA #2 | Certified Nursing Assistant | Reported transferring residents alone due to low staffing. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 26, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident abuse and inadequate pain management at the facility.
Complaint Details
The complaint investigation was substantiated with findings of physical abuse by a CNA to a resident, inadequate pain management resulting in immediate jeopardy, and infection control lapses. The facility was notified of immediate jeopardy on 05/19/23 and again on 05/24/23 due to ongoing issues.
Findings
The facility failed to prevent physical abuse by a Certified Nurse Aide to a resident, resulting in physical and mental harm. Additionally, the facility failed to provide appropriate pain management for multiple residents, including failure to assess and administer pain medication as ordered, and incomplete pain assessments. Infection control deficiencies related to nebulizer and glucometer cleaning were also identified.
Deficiencies (3)
Failed to prevent resident abuse by a Certified Nurse Aide hitting a resident.
Failed to provide safe, appropriate pain management for residents, including failure to assess and administer pain medication and incomplete pain assessments.
Failed to implement proper infection prevention and control protocols for nebulizers and glucometer cleaning.
Report Facts
Residents affected by abuse: 1
Residents affected by pain management deficiencies: 4
Residents affected by infection control deficiencies: 2
Dates of survey completion: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #2 | Named in physical abuse finding for hitting resident R #12. | |
| Licensed Practical Nurse (LPN) #2 | Witnessed and intervened in abuse incident involving CNA #2 and resident R #12. | |
| Director of Nursing (DON) | Interviewed regarding awareness of abuse incident and pain management deficiencies. | |
| Scheduler (SCH) | Reported abuse incident and asked CNA #2 to leave resident's room. | |
| Administrator (ADM) | Confirmed notification and actions taken regarding abuse incident. | |
| Registered Nurse (RN) #2 | Interviewed regarding pain management and resident R #23's fracture and pain. | |
| Assistant Director of Nursing (ADON) | Administered delayed pain medications on 05/14/23 for resident R #86. | |
| Licensed Practical Nurse (LPN) #3 | Observed using glucometer and cleaning it improperly. | |
| Registered Nurse (RN) #3 | Assessed resident R #37 after fall and administered medications. |
Inspection Report
Routine
Deficiencies: 15
Date: May 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident preferences, incomplete and inaccurate medical documentation, inadequate pain management, insufficient staffing, improper medication storage and administration, lack of timely dental care, incomplete nurse aide training, and failure to follow infection control protocols.
Deficiencies (15)
Failure to reasonably accommodate resident needs and preferences including providing an assisted device without orders and not honoring resident's right to choose physician or reschedule appointments.
Failure to ensure current documentation of code status for a resident, resulting in potential denial of end-of-life care choices.
Failure to document efforts to resolve a resident grievance and failure to document in-service training related to grievance.
Failure to complete and submit Minimum Data Set (MDS) assessments in a timely manner for multiple residents.
Failure to ensure discharge MDS assessment was accurate regarding change of condition and discharge date.
Failure to revise care plan to include oxygen use for a resident.
Failure to meet professional standards of quality by not following physician orders for wound care and providing antidepressant without depression indication.
Failure to provide appropriate pain management including assessment, medication administration, and documentation for multiple residents, resulting in immediate jeopardy.
Failure to provide sufficient nursing staff to meet resident needs, resulting in delayed medication administration and inadequate care.
Failure to complete annual performance review for a Certified Nurse Aide.
Failure to ensure psychotropic medication orders included appropriate indication and diagnosis.
Failure to ensure medications were stored properly, medication carts locked when unattended, and medications not left on bedside tables.
Failure to ensure communication and documentation of hospice services in resident records.
Failure to use infection control protocols for storage and cleanliness of nebulizers and glucometer.
Failure to ensure Certified Nurse Aides received required annual in-service training hours.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 27
Shifts worked: 8
Shifts worked: 19
Shifts worked: 6
Hours of training completed: 10.75
Hours of training completed: 1.5
Residents affected: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Confirmed loose pill in medication cart and lack of hospice binder |
| RN #3 | Registered Nurse | Provided post-fall assessment for resident #37 |
| RN #4 | Registered Nurse | Interviewed about staffing on 05/14/23 |
| RN #5 | Registered Nurse | Interviewed about staffing on 05/14/23 |
| RN #6 | Registered Nurse | Administered medication to resident #95 but failed to document |
| DON | Director of Nursing | Multiple interviews confirming deficiencies and expectations |
| CNA #3 | Certified Nurse Assistant | Reported delay in medication administration for resident #95 |
| CNA #4 | Certified Nurse Assistant | Confirmed loose pills should not be on bedside table |
| LPN #3 | Licensed Practical Nurse | Confirmed medication administration protocols |
| LPN #2 | Licensed Practical Nurse | Confirmed medication cart left unlocked |
| Assistant Director of Nursing | ADON | Came in late on 05/14/23 to cover nursing shifts |
| Social Services Director | SSD | Interviewed about resident grievances and dental care |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed about resident dental pain |
| Assistant Manager Dietary | Assistant Manager | Confirmed food safety violations |
| Medical Records Clerk | Medical Records Clerk | Confirmed no hospice binders present |
| Registered Nurse #2 | Registered Nurse | Confirmed medication cart unlocked |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed glucometer cleaning |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, care, safety, and facility environment at Santa Fe Care Center.
Findings
The facility was found deficient in multiple areas including failure to honor resident shower preferences, inaccurate documentation of advance directives, failure to maintain a clean and homelike environment, delayed grievance responses, improper oxygen therapy administration, inadequate monitoring and intervention for significant weight loss, and unsafe food storage and sanitation practices.
Deficiencies (7)
Failure to assist residents to shower per their requested schedule and not providing visitors a restroom within the building.
Failure to ensure resident's advance directives were accurately reflected in the Electronic Medical Record.
Failure to maintain a homelike environment by not keeping resident rooms clean and free of clutter.
Failure to respond timely to grievances received by residents and Resident Council.
Failure to meet professional standards of care by not labeling and dating oxygen tubing per physician orders and administering oxygen without physician orders.
Failure to monitor and intervene for significant weight loss in a resident, resulting in continued decline.
Failure to store and serve food under sanitary conditions including unlabeled and undated food items, improper storage, and unclean freezer.
Report Facts
Residents reviewed for shower preference deficiency: 3
Weight loss percentage: 8.5
Weight loss percentage: 11.3
Number of grievances with delayed response: 4
Number of residents affected by food safety deficiency: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Involved in shower scheduling and resident shower preference confirmation | |
| Certified Nursing Assistant #2 | Completed Shower Preference form and confirmed resident shower preferences | |
| Director of Nursing | Director of Nursing | Provided information on showering process, oxygen tubing standards, and advance directive documentation |
| Administrator | Administrator | Provided visitor policy and confirmed food storage and freezer cleanliness issues |
| Social Services Assistant | Social Services Assistant | Assisted resident and family with Medical Orders for Scope of Treatment and confirmed EMR inaccuracies |
| Lead Certified Nursing Assistant | Lead Certified Nursing Assistant | Confirmed presence of bed pans in resident room and discussed resident continence |
| Social Services Director | Social Services Director | Confirmed grievance process and timeliness issues |
| Registered Nurse #1 | Registered Nurse | Confirmed oxygen tubing change frequency and deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed resident on hospice and code status |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Discussed resident diet and weight loss monitoring |
| Registered Nurse #2 | Registered Nurse | Discussed resident referral to hospice for weight loss |
| Registered Dietician | Registered Dietician | Discussed resident weight loss monitoring and notification delays |
| Cook #1 | Cook | Confirmed food labeling and storage deficiencies |
| Lead Cook | Lead Cook | Confirmed food labeling and storage deficiencies |
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