A list of the most recent deficiencies for Santa Fe Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-21 | 2024-01-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-21 | 2024-01-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-21 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-21 | 2024-01-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-21 | 2024-01-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-21 | 2024-01-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-21 | 2024-01-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-26 | 2023-07-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-26 | 2023-07-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-26 | 2023-07-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-26 | 2023-07-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-26 | 2023-07-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-26 | 2023-07-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-26 | 2023-07-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-26 | 2023-07-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-26 | 2023-07-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-26 | 2023-07-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-26 | 2023-07-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-26 | 2023-07-10 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-05-26 | 2023-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-26 | 2023-07-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-26 | 2023-07-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-05-26 | 2023-07-10 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-26 | 2023-07-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-26 | 2023-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-26 | 2023-07-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-19 | 2023-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-03-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-16 | 2023-03-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-20 | 2022-11-23 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-20 | 2022-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-20 | 2022-11-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-11-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-20 | 2022-11-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-20 | 2022-11-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-07-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-24 | 2022-04-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-24 | 2022-04-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-24 | 2022-04-30 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-24 | 2022-04-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-24 | 2022-04-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-24 | 2022-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-04-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-22 | 2022-04-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-22 | 2022-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-22 | 2022-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-22 | 2022-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-22 | 2022-04-30 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-02 | 2021-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-09-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-02 | 2021-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-02 | 2021-09-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-02 | 2021-09-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-01 | 2021-03-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-01 | 2021-03-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-03-01 | 2021-03-31 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-01 | 2021-03-31 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-03-01 | 2021-03-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-03-01 | 2021-03-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-03-01 | 2021-03-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-01 | 2021-03-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-01 | 2021-03-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-03-01 | 2021-03-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-01 | 2021-03-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-01 | 2021-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-01 | 2021-03-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-01 | 2021-03-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-01 | 2021-03-31 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-03-01 | 2021-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-01 | 2021-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-01 | 2021-03-31 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-01 | 2021-03-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-02 | 2021-03-31 | N |
