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🔎 Santa Fe Health And Rehabilitation Center

Inspection Results


Inspection Overview

Santa Fe Health And Rehabilitation Center has been cited for a total of 27 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Ensure residents have reasonable access to and privacy in their use of communication methods.

Survey Date: 2025-02-21
Correction Date: 2025-03-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-02-21
Correction Date: 2025-03-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-02-21
Correction Date: 2025-03-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-03-15
Correction Date: 2024-04-01
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: 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.

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-01-25
Correction Date: 2024-03-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2022-11-04
Correction Date: 2022-12-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2022-11-04
Correction Date: 2022-12-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2022-11-04
Correction Date: 2022-12-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-11-04
Correction Date: 2022-12-04
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-09-28
Correction Date: 2022-10-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2022-09-28
Correction Date: 2022-10-12
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-09-28
Correction Date: 2022-10-12
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-06-07
Correction Date: 2022-06-24
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-10-23
Correction Date: 2021-11-12
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2021-09-03
Correction Date: 2021-10-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2021-09-03
Correction Date: 2021-10-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2021-09-03
Correction Date: 2021-10-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-09-03
Correction Date: 2021-10-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2020-01-15
Correction Date: 2020-03-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2020-01-15
Correction Date: 2020-03-01
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-01-15
Correction Date: 2020-03-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-01-15
Correction Date: 2020-03-01
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**