One morning in October, a resident of the Casa Real nursing home in Santa Fe called his sister, saying he was in pain and couldn’t get anyone at the facility to respond, according to a state inspection report.

The sister contacted a hospice nurse outside Casa Real, who went to the nursing home and found the resident’s stomach swollen and his urine bag empty, the report said. The hospice nurse changed the man’s urinary catheter, which was blocked, and drained about 85 ounces, well more than half a gallon, of urine.

“I believe that no one had monitored [the resident] for 12 hours,” an inspector wrote. “The dangers are that his bladder could rupture and he could get a bladder infection. [Certified nursing assistants] are nonexistent or are overworked and sometimes you can’t find a nurse so the response time is slow.”

The report on that incident and results of other inspections at Casa Real during the past year paint a troubling picture of life at the nursing home: medication errors, expired food and drugs on shelves, unreported injuries and assault, poor care of wounds, inadequate safeguards against spread of antibiotic-resistant infection, nurse understaffing and more.

“I just pray to God I never have to go into a facility like that,” said Noel Valencia, whose elderly mother, Antonia Tanuz, died in 2010 about 2½ months after being admitted to Casa Real. A wrongful death lawsuit, settled out of court for an undisclosed sum, said Tanuz developed a bedsore at the nursing home and died of an infection.

Problems also have occurred at the Santa Fe Care Center, a sister facility of Casa Real, according to inspection reports.

A resident at the Santa Fe Care Center was threatened with eviction last year because his family complained about his care, an inspection found. The inspector also reported seeing staff ignore a woman’s repeated pleas for help as she sat in a wheelchair near a nursing station.

The troubles at Casa Real and the Santa Fe Care Center aren’t new. State inspectors in at least the past 15 years have cited serious deficiencies in resident care. Ownership of the homes, now operated by Preferred Care Partners Management Group of Plano, Texas, has changed several times.

State and federal regulators have allowed the homes to continue to operate and accept Medicare and Medicaid payments, although the facilities have faced substantial fines. Casa Real was recently placed under increased supervision by the federal Centers for Medicare and Medicaid Services and faces a threat of decertification from the insurance programs if it doesn’t improve quality of care.

The state Department of Health, which licenses and inspects Casa Real and the Santa Fe Care Center, declined to comment.

The for-profit facilities are the only skilled-nursing homes in Santa Fe that take Medicare and Medicaid payments, meaning area residents must accept conditions at the homes if they cannot afford private-pay nursing and want to stay in Santa Fe.

Conditions at the nursing homes are becoming more critical, given the rise in the average age of Santa Fe residents in recent years.

Casa Real and the Santa Fe Care Center, whose residents are largely Medicare and Medicaid recipients, each have an overall rating of one star out of five possible stars from the Centers for Medicare and Medicaid Services. One star means “much below average,” according to the agency.

The office of the state long-term care ombudsman, which serves as an advocate for nursing home residents, reported 428 complaints against Casa Real and 105 complaints against the Santa Fe Care Center in the past two years. The top complaints dealt with discharge, administration of medications, staff attitudes and failure to deliver ordered care.

More than 62 percent of the complaints against Casa Real and nearly 45 percent of the complaints against the Santa Fe Care Center were substantiated, according to the ombudsman office.

Casa Real was recently named a “special focus facility” by the Centers for Medicare and Medicaid Services because of the nursing home’s history of problems over several years. The focus status is given to the nation’s poorest-performing homes, and Casa Real will be subject to more frequent inspections as a result of the designation.

Casa Real has been assessed nearly $203,000 in federal fines in the past three years, according to the Centers for Medicare and Medicaid Services. The Santa Fe Care Center was fined a total of more than $204,000 in 2015 and 2016.

Conditions at both nursing homes are the subject of a lawsuit filed against their operators by the state Attorney General’s Office, which alleges the homes received hundreds of millions of dollars from Medicare, Medicaid and private payers without delivering even basic care.

Also, since 2003, Casa Real has been sued at least 13 times for wrongful death in caring for residents, according to court records. It denied the allegations. Ten of the 12 cases were settled or otherwise dismissed prior to trial. It isn’t clear from court records whether some cases were dismissed because of settlements or other reasons. Three cases are pending.

The Santa Fe Care Center has been sued at least twice for wrongful death and twice for negligence since 2010, court records show. It also denied the allegations, and those cases never made it to trial because of dismissal due to settlement or other reasons.

The nursing homes and Preferred Care, their operator since 2012, didn’t respond to requests for interviews to discuss conditions at Casa Real and the Santa Fe Care Center and to provide tours of the homes. Preferred Care has denied the allegations in the lawsuit filed by the Attorney General’s Office.

Unexplained injuries

Suzette Lucero said her father, Robert Piñeda, a former Santa Fe city manager and a former Santa Fe County manager, was admitted to Casa Real in August 2012 for rehabilitation after falling and breaking a kneecap.

“We figured four weeks, in and out,” Lucero said in a recent interview. He was dead four months later, the result of a bedsore developed while at the nursing home, she said.

“He got thrown into a house of horrors and had an agonizing and horrific death,” Lucero said.

Piñeda was 69. A wrongful death lawsuit against Casa Real was settled out of court for an undisclosed sum.

The 118-bed Casa Real, open since 1984, is located on Galisteo Street near Christus St. Vincent Regional Medical Center. It’s a nondescript brown stucco building. The lobby has a Santa Fe-style feel with brown tiles and wood posts and beams.

“Casa Real offers the convenience of location in Santa Fe, NM combined with our excellent skilled and caring clinical and rehabilitation staff,” the home’s website says. “At Casa Real, you’ll enjoy our warm and compassionate services …”

Inspectors of the state Department of Health have found something different.

The department conducted its last standard health inspection of the nursing home in April and reported 37 deficiencies, more than three times the average number of health deficiencies found in all New Mexico nursing homes. Among the reported problems:

• Medications were not administered at proper doses or on time. One resident was supposed to be given a medication daily but didn’t receive it on 13 days in March. Also, residents didn’t receive medications because the home didn’t have them available. Expired medications were found in drug storage.

• A female resident who was supposed to receive a shower three times a week hadn’t had a shower for a week. “I got a shower cause I was begging for it,” the resident told an inspector.

• Bathroom pull cords for call lights were unreachable if a resident fell.

• Residents were not receiving the number of physical therapy sessions ordered by physicians. “This deficient practice … is likely to increase falls resulting in bruises, lacerations, broken bones, head trauma and death,” the inspector’s report said.

• Food was not served at the proper temperature, and food in refrigerators was older than its expiration date.

The Department of Health also conducted limited inspections of Casa Real in September and November after it received complaints.

The November inspection was the result of a complaint over the care provided to the resident whose blocked urinary catheter was discovered by the hospice nurse.

“During further investigation, the [inspection] team discovered that another resident … had also recently had an obstructed urinary catheter that went unnoticed by staff, until family alerted staff that the urinary catheter bag was empty,” the inspection report said.

The report said some of the home’s residents were in immediate jeopardy as a result of improper care of urinary catheters.

An inspector also reported hearing a Casa Real nurse say she was glad a male resident had been transferred to a hospital because he was a “pain in the ass.”

The September complaint inspection found that Casa Real failed to report resident injuries of unknown origin to the Department of Health and submit required followup investigations.

In addition, the nursing home failed to promptly report that a male resident had been found by an aide in a female resident’s room with his hands on the woman’s chest as she slept, according to the inspection report. The aide escorted the man out of the room. Casa Real didn’t have a plan to address the man’s “inappropriate sexual behavior, wandering and resident-to-resident abuse,” the report said.

The investigation report also noted deficiencies in caring for a wound to a woman’s knee, insufficient nurse staffing and inadequate controls in preventing spread of a resident’s methicillin-resistant Staphylococcus aureus infection. The illness, also known as an MRSA infection, can be life-threatening because the bacteria that causes it has become resistant to many antibiotics.

The website for the Centers for Medicare and Medicaid Services shows all the deficiencies listed in the inspections of Casa Real over the past year have been corrected, but that doesn’t mean inspectors won’t find the same, similar or new problems in their next inspection.

The 2016 standard health inspection of Casa Real found 39 deficiencies, and the 2015 inspection found 25. All those problems also were reported as being corrected.

The Centers for Medicare and Medicaid Services designated Casa Real a special focus facility in May. It will be subject to about two standard inspections a year instead of one.

The agency said it created the special focus facility initiative because nursing homes with a “ ‘yo-yo’ or ‘in and out’ compliance history rarely addressed underlying systemic problems that were giving rise to repeated cycles of serious deficiencies.”

One other special focus facility is in New Mexico. It is the Sagecrest Nursing and Rehabilitation Center in Las Cruces, which is operated by the same group that runs Casa Real. The home has been in focus status for nearly two years.

Dusty McDaniel, a chaplain who serves Casa Real residents, said in a recent interview in the home’s parking lot that he has seen improvements at the facility in the past 18 or so months.

“You’ve got doctors that care, for one,” McDaniel said. The residents were previously treated by one physician who also was responsible for residents of at least two other nursing homes, one in Albuquerque, he said.

The chaplain also said Casa Real is cleaner now and has more concerned staff.

While the home has an overall one-star rating from the Centers for Medicare and Medicaid Services, it has a three-star, or average, rating for staffing and a four-star, or above-average, rating for registered nurse staffing.

Casa Real also was given a three-star rating for two dozen quality measures, reflecting a mix of good and bad. For example, its percentage of long-stay residents experiencing falls with major injuries was below the state average. But it ranked poorly when it came to short-stay residents who made improvements.

Threatened discharge

John “Jack” Conant, a retired Sandia National Laboratories chemist, was admitted to the Santa Fe Care Center in December 2010 for nursing care and rehabilitation following partial hip replacement surgery.

“He was OK when he went in,” said his wife of more than 50 years, Georgianne Conant.

Jack Conant’s stay was a brief one. About two weeks after being admitted to the Santa Fe Care Center, he fell, according to a lawsuit. Despite intense pain, he wasn’t transferred to a hospital until three days after the fall, the lawsuit said, adding that hospital doctors found he had a dislocated hip, as well as an advanced bedsore.

Jack Conant died in March 2011 because of complications of a hip fracture, sepsis from bedsore infections, and a lung infection, according to the lawsuit, which alleged the Santa Fe Care Center and Cathedral Rock, then owner of the nursing home, were negligent.

The Conant family, the Santa Fe Care Center and Cathedral Rock settled the case out of court for an undisclosed sum.

“That care center is terrible,” Georgianne Conant said in a recent interview. “The people that are there need help. They just don’t get it.”

The 120-bed Santa Fe Care Center, open since at least 1999, is located on Harkle Road near its sister facility. There’s a rose garden out front.

Like Casa Real, the Santa Fe Care Center promises quality care. The listed amenities for both homes include social outings and gatherings, beauty and barber services, complimentary Wi-Fi and a monthly “Chef’s Selection Dinner, which showcases gourmet cuisine from around the world.”

The Health Department conducted its last standard inspection of the home in September and reported 14 health deficiencies.

A relative of a female resident said he had numerous concerns about the woman’s care, including inadequate responses to the resident’s inhalation of fluid or solids, inappropriate positioning of the woman’s neck, late medications and the woman’s foot dragging on the floor while she was being taken for a shower, the inspection report said.

After filing a complaint with the Department of Health, the family was served by the Santa Fe Care Center with a notice of involuntary transfer or discharge of the woman in 30 days, the report said.

“The [home’s administrator] verified that the reason why the family was given the notice of discharge was due to the constant and numerous unreasonable requests, allegations and complaints made by the family,” the report said.

The report said the Santa Fe Care Center was deficient in allowing residents to “voice a complaint or grievance without being treated differently or badly.”

The report doesn’t say whether the woman was allowed to stay at the nursing home.

The inspection also found some residents weren’t getting prescribed medications and that the nursing home failed to record, prevent and deal with dramatic weight loss by some residents.

A complaint inspection of the Santa Fe Care Center was conducted in July 2016. It found the home had waited at least 48 hours to advise a physician about a new resident’s significant deterioration in mental and physical function.

A urinary tract infection went undetected and led to a life-threatening infection, insufficient blood flow to the organs and acute kidney injury, the inspection report said.

The female resident was taken to a hospital four days after being admitted to the Santa Fe Care Center, the report said. During her short stay at the nursing home, according to a family member, she had to sit in fecal matter while waiting for help for incontinence.

Like its sister facility, the Santa Fe Care Center has a history of poor performance in standard inspections. Inspectors reported 22 deficiencies in 2015 and 13 in 2014.

The Centers for Medicare and Medicaid Services has given the nursing home a four-star, or above average, rating for staffing and registered nurse staffing, but it gave the Santa Fe Care Center one star when it came to quality measures. For example, the nursing home performs poorly when it comes to short-stay residents who make improvements, short-stay residents with new or worsened bedsores and long-stay residents whose ability to move independently worsened.

On a recent morning, a woman who identified herself only as Theresa was visiting her mother at the Santa Fe Care Center. She said she has found the staff and therapists attentive to residents but the home is small, with double rooms and a garden for residents.

“I’m OK with the care,” she said. “I want a better facility.”

“The problem is that there are not many options” in Santa Fe for Medicare and Medicaid patients, the woman said. “People who don’t have a lot of money end up here. I think more options would make these places better.”

State lawsuit

The Attorney General’s Office filed its lawsuit in 2014 against Preferred Care Partners Management Group, the operator of Casa Real and the Santa Fe Care Center.

The lawsuit alleges that Preferred Care defrauded Medicaid by having insufficient staff to meet the needs of residents at its Santa Fe nursing homes, as well as at facilities in Gallup, Las Cruces, Bloomfield, Española and Lordsburg. Also named as a defendant is Cathedral Rock, former owner of the homes.

The lawsuit has been controversial because of the political connections of the outside lawyers assisting the Attorney General’s Office, as well as the novel premise of the case: that based upon thin staffing, the homes were incapable of delivering basic care to residents, including assistance with bathing, meals and toileting.

Preferred Care has called the lawsuit “a textbook case for these lawyers who put money in the campaign coffers of attorneys general across the country and then push them to file questionable claims.”

The lawsuit says the state has witnesses, including family members and nursing home staff, who will support the claims of inadequate care.

Lucero, whose wrongful death lawsuit against Casa Real was settled, said she is prepared to testify for the state.

“I don’t want another family to go through what we went through and what my father went through,” she said.

The attorney general’s lawsuit is scheduled for trial in the spring in state District Court in Santa Fe.

Contact Thom Cole at 505-986-3022 or

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