Santa Fe Care Center Violations & Ratings

Santa Fe Care Center, located in Santa Fe, New Mexico, is a medium-sized nursing facility meant to provide care for individuals who need assistance with daily living. However, this nursing home has been accused of failing to provide safe, high-quality medical treatment to its clients, putting them at risk of serious complications.

If your loved one has developed complications after being admitted to Santa Fe Care Center, it’s crucial to report the issue to prevent further harm to others. Contact our New Mexico nursing home lawyers today for a free consultation, and we will help you create a plan of action, including legal avenues for redress.

Quick Overview

• Facility Name: Santa Fe Care Center
• Address: 635 Harkle Road, Santa Fe, NM, 87505
• CMS Overall Rating: 1 out of 5 stars 
• CMS Health Inspection Rating: 1 out of 5 stars
• CMS Staffing Rating: 2 out of 5 stars 
• CMS Quality Measures Rating: 3 out of 5 stars 
• Federal Fines in Last 3 Years: 32 fines totaling $286,009
• Payment Denials by Medicare in the Last 3 Years: 1 denial
• Total Bed Capacity: 120 beds
• Ownership Type: For-Profit LLC [1]

Facility Overview

Santa Fe Care Center is a 120-bed facility that provides 24-hour skilled nursing services to clients with a variety of needs, including patients with dementia or complex medical issues. This nursing home also provides short-term rehabilitation, long-term residential living, and day programs for respite care. 

The Santa Fe Care Center is an independent nursing home that is not associated with a hospital or retirement community. 

CMS Ratings and Performance

All nursing homes, hospitals, and rehabilitation facilities participating in Medicare and Medicaid are rated on a 5-star system by the Centers for Medicare and Medicaid Services (CMS). This system is meant to ensure that facilities receiving government benefits meet the program’s goals, such as fulfilling residents’ needs for pain management, rehabilitation, and social activities. This score comprises three subsections: health inspections, staffing, and quality measures, such as how many residents were placed on antipsychotic drugs.

The Santa Fe Care Center has a 1-star overall rating. Its health inspection score was 1 out of 5 stars, while staffing was rated 2 out of 5.[1]This is partly due to its very high turnover rate: 69.8%, well above the 49.1% national average and the 55.4% New Mexico state average.[1]

On quality measures, the Santa Fe Care Center received 3 out of 5 stars. Its ratings were better for short-term stays than long-term stays.

The nursing home has received 32 separate federal fines in the last three years, resulting in $286,009 in fines. It has also had one Medicare denial. 

The Occupational Safety and Health Administration has also penalized the facility for failing to protect nursing staff from hazards like respiratory infections. 

Services Provided

This nursing home offers a full complement of services, including 24-hour patient care for short-term and long-term stays. They have an on-site physician and nutritional services, as well as vehicles and staff that will assist residents in getting to off-site appointments like dialysis. Some of the services available at Santa Fe Care Center include:

•  Physical therapy
• Occupational therapy
• Speech therapy
• Wound care
• Diabetes management
• Dementia and memory care
• Respite care
• Post-operative care
• IV therapy
• Psychological care
• Social workers
• Hospice care

Inspection reports show that Santa Fe Care Center has significant staffing issues, which is echoed in resident reviews. Reviewers complain that the nursing staff failed to provide pain medication to their loved ones and that the facility was in a state of disarray every time they visited. 

In addition, another reviewer noted that they were told not to visit their family member, which directly opposes state law that affords nursing home residents certain rights and privileges. 

Violations and Citations

Since September 2021, ProPublica has recorded 84 total deficiencies at Santa Fe Care Center, including 5 infection-related deficiencies. These reports provide insight into the potential dangers that may face a resident placed in the facility so that loved ones can make the best decisions about their family member’s care.

Specific Violations

Some specific violations that Santa Fe Care Center has been charged with include the following. 

Failure to Provide Appropriate Pressure Ulcer Care: A November 2023 inspection found that a resident had developed a fluid-filled abscess, and the facility failed to implement an appropriate pressure ulcer care regimen or note the newly developed pressure ulcer on the resident’s chart. This, combined with several other deficiencies, was grounds to charge the facility a $13,039 fine. 

Failure to Provide Adequate Pain Relief: In a May 2023 complaint, a nursing home resident suffered a fall and reported significant discomfort that was not alleviated by the provided medication. Nurses failed to contact a doctor and ask for a stronger prescription, even when the resident consistently reported that the drugs provided were not helping. After over a day, the nursing home transported the resident to a local hospital, where it was found that he had fractures in both legs above the knee joint. 

Resident Abuse and Neglect: A May 2023 complaint noted that a Certified Nursing Assistant from a staffing agency hit a resident multiple times. A nurse who was passing out medication at the time intervened, forcing the CNA to leave the room and then check to see whether the resident was in pain. The Director of Nursing for the facility stated that she did not know what training procedures were in place at the staffing agency, and the report failed to note whether there was any reprisal or punishment for the abusive CNA.

Lack of Assessments: A standard inspection in May 2023 found that the Santa Fe Care Center did not transmit accurate resident assessments to the New Mexico Department of Health within 7 days, a crucial provision to ensure that every resident is cared for. One resident’s only assessment was from over a month ago, which meant the nurses could not provide for any emergent needs. 

Lack of Wound Care: A November 2023 report found that residents with open wounds did not have a wound care plan in place, which could lead to complications. 

Failing to Seek Medical Treatment: The nursing home was cited in November 2023 when nurses failed to send a resident to the emergency room for a fractured kneecap, instead waiting three days to transport them.

Failing to Provide Appropriate Treatment: In November 2023, nurses did not immediately assist when a resident began to refuse food, even though the resident was diabetic. He went without food for over an entire day before finally being sent to the emergency room. The resident’s son stated that his mother was the one to demand her husband be sent to the emergency room, even though the nursing home admitted that the resident had not been eating.

Impact on Residents

Violations at the Santa Fe Care Center nursing home seriously imperil every resident. Not only do these problems violate a resident’s right to live free from abuse and neglect, but they can also cause worsening of underlying health conditions and the development of psychological issues. 

Health and Safety: Adequate Supervision

The Santa Fe Care Center consistently fails to supervise every patient adequately. On average, the nursing home offers only 3 hours and 24 minutes of nurse hours per resident per day, which is not enough to meet all residents’ needs. [1]

The nursing facility has been cited multiple times for lacking enough team members to meet the needs of every resident, showing that this is a long-standing issue. 

Nurse aides provide most of the care instead of licensed or registered nurses, meaning residents with comorbid conditions may not have all their basic needs fulfilled, such as receiving appropriate pressure ulcer care.

This lack of supervision also includes a failure to provide safe environments for every resident, as evidenced by the example of a nurse aide hitting a patient repeatedly. Individuals who refused food were not immediately reassessed or sent to the emergency room for further investigation, which could have caused major issues with their long-term care.

Emotional and Psychological Impact

An abusive environment may make a resident hesitant to speak up about issues, as they fear reprisal in the form of verbal or physical abuse. This can lead to fear, anxiety, depression, and even aggression if a resident feels that their needs are not being met.

The Centers for Medicare and Medicaid Services notes that a high percentage of patients at this nursing home are receiving antipsychotic drugs, which are often used to keep individuals compliant rather than to treat an underlying medical condition. [1]

These drugs can have serious side effects both mentally and physically, primarily if used as an off-label sedative. They can prevent individuals from being able to participate in everyday life, causing them to lose motivation or to neglect their self-care. 

Case Examples

In addition to the above examples, a May 2023 complaint found that one resident missed a necessary physician appointment because the transport van never arrived to pick him up. This failure to provide transport could have significantly impacted the resident’s care.

The same report noted that one resident’s code status was incorrect; he was stated as being a Full Code, meaning that the facility would provide all necessary life-saving measures if he were to go into cardiac arrest. In reality, the resident wanted a code of Do Not Resuscitate, which means that physicians should not provide any life-saving measures if he were to experience cardiac arrest.

This failure would prevent the resident from dying with dignity and expose him to significant discomfort contrary to his wishes.

Another individual at the nursing home developed sepsis after nurse aides failed to send him to the emergency room immediately after a fail. This life-threatening complication not only resulted in needless suffering but it also could have killed him.

Legal Rights and Actions

The New Mexico legal code outlines the rights of every individual living in a nursing home, including the right to live without fear of abuse or neglect. Those whose rights are violated can file a lawsuit for nursing home abuse, which will hold the facility accountable and secure financial compensation to cover the suffering caused.

Pursuing legal action against a nursing home can be complicated, which is why families should partner with an experienced nursing home abuse lawyer to review their options. Our Nursing Home Law Center team can guide you through the entire process and safeguard your privacy. Contact us today for a free consultation.

[1] Medicare