Santa Fe Care Center

The complaint inspection on October 20, 2022, revealed multiple instances of nursing home neglect. 

Reprisal Against Residents Exercising Their Rights 

Santa Fe Care Center retaliated against three residents who exercised their right to leave the facility early in response to receiving substandard care. In all three cases, Santa Fe Care Center refused to provide the residents with their medications and discharge paperwork. 

The administrator informed the inspector that the policy was that residents who chose to leave against medical advice would not receive medications or discharge paperwork as a matter of policy. The surveyor disagreed and cited the facility.

Improper Discharge of a Resident With COVID-19  

When a resident and his two family members contracted COVID-19 in the facility, the resident chose to leave due to the negative mental health effects of COVID isolation. He also had not received his prostate medication for three weeks.  

The nursing home classified the discharge as against medical advice and refused to provide his medications and paperwork. A physician told the inspector that the against-medical-advice classification was improper. 

Delayed Pain Management 

A resident left the facility against medical advice after a serious delay in receiving pain medication. Staff did not ask why she was leaving, made no effort to persuade her to stay, and refused to provide her medications or her paperwork. In addition to the citation for reprisal, the facility was cited for delayed pain management. 

Negligent Care of Motor Vehicle Collision Injuries  

Santa Fe Care Center failed to identify that a resident with multiple injuries from a motor vehicle collision had a broken foot and a burn. Staff forced him to walk on it and failed to treat the burn. His mother removed him and took him straight to the hospital after he told her he could no longer bear the pain.  

The facility refused to provide his medications or paperwork upon discharge. The burn injury was infected when he was admitted to the hospital.  

A review of the records showed that Santa Fe Care Center had no admission or progress notes and no care plan. The nursing home did not ask why he was leaving or attempt to persuade him to stay.  

In addition to the reprisal citation, the facility was cited for: 

• Failure to implement a care plan within 24 to 48 hours of admission 
• Failure to provide appropriate treatment and care 
• Failure to provide safe, appropriate pain management 
• Failure to maintain accurate medical records  

Insufficient Pressure Ulcer Care 

Pressure ulcers (bedsores) are almost always caused by neglect. Santa Fe Care Center failed to provide appropriate pressure ulcer care and prevent new pressure ulcers from forming in at least one resident by failing to:  

• Assess and document wounds weekly 
• Document all pressure wounds and the condition of each wound  
• Notify the resident’s health-care provider when the resident needed to be assessed for a potentially higher level of care