Casa Real
Casa Real in Santa Fe, NM — inspection on March 26, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
#1) resident reviewed for catheter care had a privacy cover on their drainage bag while seated in the
medical device being visible to other residents and staff, thereby failing to maintain the resident's dignity.The findings are:A. On 03/24/26 at 9:09 am, during an observation of the locked unit dining room, R #11 was sitting in his wheelchair.
Further observation revealed R #11's drainage bag was exposed under his wheelchair with no dignity cover.B.
Record review of R #11's physician's order revealed an indwelling catheter (tube inserted into the bladder to continuously drain urine, held in place by a retention balloon) was ordered on 02/01/26. C. On 03/24/26 at 9:11 am, during an interview with Registered Nurse (RN) #3, she confirmed R #11's drainage bag is exposed with no dignity cover on. RN #3 stated all drainage should be covered with a dignity cover and it did not have a cover.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
325038 03/26/2026
Casa Real 1650 Galisteo Street Santa Fe, NM 87505
for 2 (R #9, and R #13) of 2 (R #9, R #13, and R #15) reviewed for showers. If the facility fails to honor
does not care about their choices.
The findings are:R #9:A.
Record review of R #9's bathing schedule stated that he should receive 3 showers per week (Tuesday, Thursday, and Saturday)B. On [DATE] at 11:08 am during an interview with R #9, he stated They finally got the water working.
They wanted us to take a shower in cold water and I refused.
They only offered the sponge baths once or twice during the time the hot water was not working. If they would have offered them (sponge bath, shower) I would have taken them. I like to be clean, and I don't feel like myself if I am dirty. R #15C.
Record review of R #15 Bathing schedule stated that R #15 was to receive two showers per week: Tuesday and Thursday. D. On [DATE] at 10:45 am during an interview. R #15 stated that the shower situation had been remedied for a couple of weeks, R #15 further stated that she did receive cold showers and started to refuse showers because of how cold the water was.
The water used to run cold, and you didn't know whether or not you would get a shower.
There was a time when the water was nice and warm then it got cold while I still had soap, so they had to rinse it off with cold water and it was horrible.E.
Record review of Social Services Director (SSD)'s note dated [DATE] revealed, met to discuss concerns for R #15, R #15's daughter had concerns. R #15's daughter stated [name of R #15] had been declining showers and bed baths that were offered because the water was too cold. F. On [DATE] at 3:00 pm during an interview with Certified Nurse Assistant (CNA) #1, she stated that the water was ice cold. My coworker (CNA #3) decided to give residents bed (sponge) baths.
The issue with the cold water was resolved about 2 weeks ago.
Residents started to complain about the water being cold and not wanting to take around the middle of December.
There was no hot water from the middle of December until early March in the resident care areas.
Infection control Preventionist (ICP) got us big barrels of warm water, and we placed them in the shower rooms in order to offer sponge baths in the shower rooms. R #9 refused sponge baths.G. On [DATE] at 3:30 pm during an interview with Maintenance Director, (MD) stated It takes it a while for the hot water to kick in the shower room.
The part that we needed to fix the problem with the cold water in the facility was on back order and that is why it took so long to get it fixed.
325038 03/26/2026
Casa Real 1650 Galisteo Street Santa Fe, NM 87505
Federal health inspectors cited Casa Real in Santa Fe, NM for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2026-03-26.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Casa Real.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-27.
services of a licensed pharmacist.
disposed of on the north hallway, when two medications were observed in the trash bin attached to
the medication causing potential medication side effects.
The findings are:A. On 03/25/26 at 8:27 am, during an observation of the north hall nurses station, two medications were found in the trash bin attached to the medication cart.
Further observation revealed these medications were: a round blue pill stamped with 61, and an oblong orange pill stamped with 20 were together inside an unlabeled medication cup. B. On 03/25/26 at 8:28 am, interview with Registered Nurse (RN) #1, she confirmed those medications were in the trash bin.
She also stated unused medications should be disposed in the drug buster (sealed container used for drug disposal) that is located on the bottom drawer. C. On 03/25/26 at 8:34 am, during an interview with the Unit Manager (UM), he stated all unused medications are to be disposed using the drug buster and it did not happen.
The UM also stated if the medications are controlled like narcotics then two licensed personnel are to dispose the medication together and updated on the narcotic count sheet.
325038 03/26/2026
Casa Real 1650 Galisteo Street Santa Fe, NM 87505
Federal health inspectors cited Casa Real in Santa Fe, NM for a deficiency under regulatory tag F-F0761 during a complaint investigation conducted on 2026-03-26.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Casa Real.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-27.
intolerances, and preferences, as well as appealing options.
observation, interviews, and record review, the facility failed to ensure residents were served meals
reviewed:R #7 received food that they are allergic to.R #7 did not receive food according to their meal ticket.These deficient practices have the potential to make resident feel unheard, or have an allergic reaction.
The findings areR#7 A.
Record review of R #7's face sheet revealed R #7 was admitted to the facility on [DATE] with the diagnosis of an allergy to chocolate.B. On 03/26/26 at 12:16 pm, during an observation of lunch, R #7's lunch ticket revealed that R #7 is not to have any chocolate. R #7 was observed to have been served and was eating chocolate ice cream. C. On 03/26/26 at 12:18 pm. during an interview, Licensed Practice Nurse #1 (LPN # 1) stated R #7 is allergic to chocolate and she should not be eating it. D. On 03/26/26 at 12:22 pm, during an interview, Nutrition Director #1 (ND #1) stated that the meal ticket states that she should not have chocolate; ND #1 served R #7 chocolate ice cream and after R #7 requested ice cream. ND #1 stated he had not read that she was allergic to chocolate.
325038 03/26/2026
Casa Real 1650 Galisteo Street Santa Fe, NM 87505
registered or licensed dietitian, to the extent allowed by State law.
observation, record and interview the facility failed to ensure R #12 was served food in accordance
able to consume it and experience weight loss and choking risks. the findings are: R #12A.
Record review of R #12's face sheet revealed R #12 was admitted to the facility on [DATE] with the diagnosis of Hypokalemia;( a condition characterized by low blood potassium levels).B.
Record review of R #12's Minimum Data Set (MDS) revealed R #12 is to ha a regular/liberalized pureed diet. C. On 3/26/26 at 11:42 am, during an observation of lunch, R #12's lunch ticket revealed that R #12 is on a pureed diet. R #12 received whole Mandarin oranges not pureed.D. On 03/26/26 CNA #2 confirmed that R #12's dessert (mandarin oranges) were whole and not pureed.
325038 03/26/2026
Casa Real 1650 Galisteo Street Santa Fe, NM 87505
in accordance with accepted professional standards.
minimal harm Based on observation, and interview, the facility failed to protect residents' personal health information (PHI) by leaving a document unattended containing multiple residents' information (such
deficient practice is likely to result in passerby's to have unauthorized access to sensitive information, putting residents' privacy at risk.The findings are:A. On 03/16/26 at 9:04 am, during an observation of the south nurse's station, a piece of paper on a clipboard with complete residents information (full name, assigned room number and code status) was left unattended and exposed to public view.B. On 03/16/26 at 9:06 am, during an interview with Registered Nurse (RN) #2, he confirmed the list contained resident's list, assigned room number and their code status was left exposed to public view and unattended. RN #2 confirmed that personal health information should not be left unattended.
Federal health inspectors cited Casa Real in Santa Fe, NM for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2026-03-26.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Casa Real.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-27.