Santa Fe Care Center

In the surveyor’s words

From the most serious findings on record at Santa Fe Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF697May 26, 2023

  This 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. The findings are: 41988 A. Record review of the Pain Clinical Protocol Policy and Procedure revised March 2018 revealed 2. […]

• Actual harm, isolatedF580Oct 25, 2024

  Based 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. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. […]

• Actual harm, isolatedF684Oct 25, 2024

  Based 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 . The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. […]

• Actual harm, isolatedF684Nov 21, 2023

  Based 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. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with the following diagnoses: 1. […]

• Actual harm, isolatedF725May 26, 2023

  Based 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. The findings are: A. Record review of the facility shift staffing dated 05/14/23 revealed a Registered Nurse (RN) for Wing 1, an RN for Wing 4, and Called off- [Name of Assistant Director of Nursing (ADON) filling in] for Wings 2 and 3. B. On 05/15/23 at 3:14 pm during an interview with R #86, he stated, Yesterday [05/14/23], morning shift comes in at 6:00 am and I didn't get my medications. […]