Santa Fe Post-Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF600Sep 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure 82 residents on the behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion, regulation, or behavior]) were protected from physical abuse when:1) Resident 1 stopped taking her Zyprexa (an antipsychotic medication [medication that helps to reduce the symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking]) on 8/25/25 and a written plan of care was not developed to monitor and prevent potential inappropriate and aggressive behaviors resulting from stopping Zyprexa.2) Resident 1 slapped Resident 2 in the face on 9/5/25 and a… […]

• Immediate jeopardy, patternF741Sep 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure staff working on the facility's behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior]) had appropriate training, skill sets, and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) to provide appropriate care to the 54 residents on the BHU with mental and psychosocial disorders, and residents experiencing suicidal ideation (SI- thoughts of self-harm and/or the killing oneself). […]

• Actual harm, isolatedF740Sep 21, 2023

  Based on interview and record review, the facility failed to ensure the necessary behavioral healthcare and services were provided to one of three residents (Resident 1) who was diagnosed with mental disorders (a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior) when: 1. Resident 1's mental disorders and history of suicidal ideation (SI, thoughts of self-harm or of killing oneself), identified upon admission, were care planned with resident-specific interventions to include providing an environment free of items that could be used to inflict self-harm. 2. […]

• Actual harm, isolatedF838Sep 21, 2023

  Based on observation, interview, and record review, the facility's Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) failed to: 1. Thoroughly assess its resident population and its ability to provide care for residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself). 2. Evaluate and identify the needs of the resident in the behavioral health unit (BHU- section of the facility's building designated for residents with mental disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior] and memory care issues) located in Station 2 and the provision of behavioral health services to residents with suicidal… […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in the facility's kitchen were maintained according to acceptable standards of practice when:Food storage areas: A a staff water bottle was stored in the walk-in refrigerator, a dented can was stored among non-dented cans, there were moldy onions infested with fruit flies circling over them were stored in the dry storage area, and water pitchers were stored wet. […]