Santa Fe Lodge

In the surveyor’s words

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

• Immediate jeopardy, patternF603Jan 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 1, 2, and 3) were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not use two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one entrance and exit) to Resident 1, 2, and 3's Room (RM 1) after CNA 1 witnessed Resident 1 spilling liquid on the floor. […]

• Immediate jeopardy, isolatedF684Mar 10, 2023

  1. Based on observation, interview, and record review, the facility failed to provide care and services for one of two sampled residents (Resident 19), who had history of aspiration pneumonia (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed), by failing to: Ensure Licensed Vocational Nurse 1 (LVN 1) transcribed (put into written or printed form) and followed Medical Doctor 1's (MD 1's) verbal order (spoken orders given by a physician to a person authorized to receive and record the orders in accordance with applicable policies, laws, and regulations) according to the facility's policy and procedure titled, Physician Orders and Telephone Orders. […]

• Actual harm, isolatedF744Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) redirected (changed direction or focus) Resident 1 to stay calm and remain by Resident 1's bedside when Resident 1 was confused (unable to think clearly), restless (inability to rest or relax), and tried to fight/hit CNA 1 on 1/17/2023 as indicated on Resident 1's care plan titled, Falling Star Program, and policies titled, Falling Star Program, Resident Care… […]

• No harm, potential for more than minimal, widespreadF867Mar 10, 2023

  Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI) team failed to: a. Identify, develop, and implement Performance Improvement Projects (PIP) based on high-risk and/or high-volume and or/ problem-prone areas affecting the health and safety of residents when they did not have a PIP for psychotropic medication reduction. b. Include quantifiable data (data that can be counted or measured) collection in its PIP related to falls. This deficient practice had the potential for the residents not to receive appropriate care and safety interventions. Findings: a. During an interview on 3/10/23, at 2:39 PM, the facility Administrator (ADM) stated the facility had a population with a high psychotropic medication use rate. […]

• No harm, potential for more than minimal, patternF552May 8, 2026

  Based on interview and record review, the facility failed to ensure the residents and/or the residents' responsible parties (RP) were informed in advance, of the risk and benefits of psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of five sampled residents (Residents 7 an 8) when:1. Resident 7's Quetiapine (Seroquel) was restarted on 3/26/2026 without an informed consent (IC-a form indicating a resident or responsible party voluntarily agree to a medical treatment or procedure after understanding the risks, benefits, and alternatives) after the Quetiapine was discontinued on 10/3/2025.2. […]