Santa Fe Heights Healthcare Center, LLC

In the surveyor’s words

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

• Immediate jeopardy, patternF600Mar 6, 2021

  Based on observation, interviews and record review, the facility failed to ensure (7) of 7 sampled residents (Residents one (1), two (2) , three (3), four (4), five (5), six (6), seven [7]) were free from abuse and adhere to its policy and procedure (P/P), which stipulated residents would be free of abuse and all allegations of abuse would be identified, reported and investigated. The facility failed to address the following: 1. Resident 3 threw a cup of water on Resident 2. Licensed Vocational Nurse 1 (LVN 1) stated the altercation between Residents 2 and 3 was not abuse. […]

• Immediate jeopardy, isolatedF602May 19, 2024

  Based on observation, interview and record review, the facility failed to ensure six of six sampled residents ' (Residents 1, 2, 3, 4, 5, and 6) personal property (debit cards) were safeguarded and were protected from potential financial abuse (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent), by failing to ensure: 1. Implementation of its undated policy and procedures (P&P) titled, Abuse Prevention, Screening and Training Program, which indicated the facility should not condone (allow) any form of resident financial abuse and misappropriation (unlawful use) of resident property and wrongful use of resident ' s money without the resident ' s consent (permission). 2. […]

• Actual harm, isolatedF600May 29, 2025

  Based on observation, interview, and record review, the facility failed to protect resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was subjected to Resident 2's physical attack, who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). […]

• Actual harm, isolatedF600Jan 23, 2025

  Based on interview and record review, the facility failed to ensure two of ten residents (Resident 6 and Resident 7) were free from physical abuse (intentional bodily injury) when: a. Resident 1 struck Resident 7 in the face unprovoked at Station A's hallway on 1/18/2025. b. Resident 5 slapped Resident 6 on the right side of the face near the vending machines because Resident 6 would not light Resident 5's cigarette on 1/7/2025. As a result of these failures, Resident 7 sustained an acute (severe and sudden in onset) depressed nasal bone fracture (a break in the nasal [relating to or having to do with the nose] bone that pushed the bone inward toward the maxilla [the bones that formed the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose] usually caused… […]

• Actual harm, isolatedF580Jan 2, 2025

  Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Change in a Resident's Condition, which indicated the facility will notify a resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition by failing to notify a physician timely, for one of seven sampled residents (Resident 2) when: a. Resident 2 had a change of condition of a decreased oxygen saturation (the percentage [%] of oxygen in a person's blood, normal oxygen saturation level between 95 and 100 %] rate oxygen of 84 %. […]