Safety Report: Santa Fe Lodge

El Monte, California · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

1Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
K
Government finding: Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected more than a very small number of residents, or happened repeatedly. Inspection of January 19, 2024, during a complaint investigation. Facility reported correction by February 12, 2024.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F603

Citations by topic

4Abuse, neglect & exploitation
3Infection control
2Medications & pharmacy
4Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (16) than in the cycle before (13).

Two cycles ago
1 serious
Prior cycle
none serious
Most recent cycle
none serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689)4June 30, 2026; May 8, 2026; October 22, 2024; March 7, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656)4June 30, 2026; March 20, 2025; March 7, 2024; January 19, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812)3May 8, 2026; March 20, 2025; March 7, 2024
Ensure that residents are fully informed and understand their health status, care and treatments. (F552)2May 8, 2026; March 20, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684)2February 5, 2026; March 20, 2025
Provide and implement an infection prevention and control program. (F880)2March 20, 2025; March 7, 2024
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (F912)2March 20, 2025; March 7, 2024

Fines and enforcement

No federal fines or payment denials in the last three years.

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

51 citations across 10 inspection dates.

August 25, 2026 — 1 citation · complaint investigation
D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F836 · complaint · corrected September 15, 2026
June 30, 2026 — 2 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 1, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected July 1, 2026
May 8, 2026 — 10 citations
E
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F881 · corrected May 26, 2026
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected May 15, 2026
E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F757 · corrected May 26, 2026
E
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F692 · corrected May 26, 2026
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected May 26, 2026
E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected May 25, 2026
E
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F552 · corrected May 26, 2026
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · corrected May 26, 2026
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected May 28, 2026
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · corrected May 25, 2026
April 7, 2026 — 2 citations · complaint investigation
E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · complaint · corrected April 27, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 29, 2026
February 5, 2026 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected February 23, 2026
March 20, 2025 — 12 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected April 10, 2025
E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F847 · corrected April 10, 2025
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected April 10, 2025
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected April 10, 2025
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F578 · corrected April 10, 2025
E
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F552 · corrected April 10, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected April 10, 2025
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected April 10, 2025
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected April 10, 2025
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected April 10, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected April 10, 2025
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected April 10, 2025
October 22, 2024 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected November 12, 2024
September 11, 2024 — 1 citation · complaint investigation
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected September 27, 2024
March 7, 2024 — 19 citations
E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected April 11, 2024
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected April 11, 2024
D
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F919 · corrected April 11, 2024
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected April 11, 2024
D
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F848 · corrected April 11, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected April 11, 2024
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F812 · corrected April 11, 2024
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · corrected April 11, 2024
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected April 11, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected April 11, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected April 11, 2024
D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected April 11, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected April 11, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected April 11, 2024
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected April 11, 2024
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F582 · corrected April 11, 2024
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected April 11, 2024
D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F553 · corrected April 11, 2024
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected April 11, 2024
January 19, 2024 — 2 citations (includes serious) · complaint investigation
K
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Immediate jeopardy to resident health or safety · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F603 · complaint · corrected February 12, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected February 12, 2024

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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