Safety Report: Santa Fe Care Center
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
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)
4Actual harm citations (severity G–I)
15Requirements cited on more than one inspection
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
G
Government finding: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F580
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
K
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Tag F725
Citations by topic
3Abuse, neglect & exploitation
3Infection control
7Medications & pharmacy
1Accidents & 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?
Fewer citations in the most recent cycle (21) than in the cycle before (25).
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.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 4 | July 2, 2026; October 25, 2024; November 21, 2023; May 26, 2023 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 4 | October 25, 2024; July 2, 2024; November 21, 2023; May 26, 2023 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 4 | July 11, 2024; November 21, 2023; May 26, 2023; March 24, 2022 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 3 | July 2, 2026; April 9, 2026; October 25, 2024 |
| 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. (F761) | 2 | July 2, 2026; May 26, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | April 8, 2025; July 11, 2024 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | October 25, 2024; November 21, 2023 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 2 | October 25, 2024; November 21, 2023 |
| Provide and implement an infection prevention and control program. (F880) | 2 | July 11, 2024; May 26, 2023 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 2 | July 11, 2024; March 24, 2022 |
| Ensure each resident receives an accurate assessment. (F641) | 2 | July 11, 2024; May 26, 2023 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F725) | 2 | November 21, 2023; May 26, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | May 26, 2023; March 24, 2022 |
| 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. (F585) | 2 | May 26, 2023; March 24, 2022 |
| 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. (F578) | 2 | May 26, 2023; March 24, 2022 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| October 25, 2024 | Fine | $12,255 |
| November 21, 2023 | Fine | $13,307 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 2, 2026 — 4 citations · complaint investigation
F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F921 · complaint · corrected August 10, 2026
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Pharmacy Service Deficiencies · F761 · complaint · corrected August 10, 2026
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected August 10, 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 August 10, 2026
April 9, 2026 — 2 citations · complaint investigation
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected May 1, 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 May 1, 2026
November 25, 2025 — 2 citations · complaint investigation
E
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 · Pattern · Pharmacy Service Deficiencies · F756 · complaint · corrected January 30, 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 · complaint · corrected January 30, 2026
April 8, 2025 — 1 citation · complaint investigation
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 April 28, 2025
October 25, 2024 — 6 citations (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected November 27, 2024
G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected November 27, 2024
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected November 27, 2024
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected November 27, 2024
D
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 · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected November 27, 2024
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 November 27, 2024
July 11, 2024 — 13 citations
F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F882 · corrected August 2, 2024
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected August 2, 2024
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected August 2, 2024
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected August 2, 2024
D
Provide or get specialized rehabilitative services as required for a resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F825 · corrected August 2, 2024
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected August 2, 2024
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected August 2, 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 August 2, 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 · corrected August 2, 2024
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 August 2, 2024
D
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F638 · corrected August 2, 2024
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 August 2, 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 August 2, 2024
July 2, 2024 — 1 citation · complaint investigation
D
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 · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected July 19, 2024
November 21, 2023 — 7 citations (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 15, 2024
F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F725 · complaint · corrected January 15, 2024
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected January 15, 2024
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected January 15, 2024
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 · complaint · corrected January 15, 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 · complaint · corrected January 15, 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 · complaint · corrected January 15, 2024
May 26, 2023 — 18 citations (includes serious)
K
Provide safe, appropriate pain management for a resident who requires such services.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F697 · corrected July 10, 2023
G
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Actual harm to a resident (not immediate jeopardy) · Isolated · Nursing and Physician Services Deficiencies · F725 · corrected July 10, 2023
F
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 · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected July 10, 2023
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Pharmacy Service Deficiencies · F761 · corrected July 10, 2023
E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F947 · corrected July 10, 2023
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 July 10, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F849 · corrected July 10, 2023
E
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F790 · corrected July 10, 2023
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · corrected July 10, 2023
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 July 10, 2023
E
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F558 · corrected July 10, 2023
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 July 10, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected July 10, 2023
D
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F730 · corrected July 10, 2023
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 July 10, 2023
D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F640 · corrected July 10, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected July 10, 2023
D
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 · Isolated · Resident Rights Deficiencies · F578 · corrected July 10, 2023
March 24, 2022 — 7 citations
F
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 · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected April 30, 2022
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 April 30, 2022
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · corrected April 30, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F585 · corrected April 30, 2022
E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F561 · corrected April 30, 2022
D
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 · Isolated · Resident Rights Deficiencies · F584 · corrected April 30, 2022
D
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 · Isolated · Resident Rights Deficiencies · F578 · corrected April 30, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare