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Casa Real

Casa Real is a significantly understaffed skilled nursing facility in Santa Fe with numerous health and safety violations that rise to the level of neglect. Levin & Perconti holds facilities like Casa Real accountable for nursing home abuse and neglect.

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Residents at Casa Real have a right to receive quality care in a supportive setting. A single instance of nursing home abuse is inexcusable. Unfortunately, residents at Casa Real live with neglect and the threat of abuse every day. The Santa Fe nursing home abuse lawyers at Levin & Perconti help victims of nursing home abuse at Casa Real get justice.

About Casa Real

Casa Real is a 118-bed for-profit skilled nursing facility that provides long-term and short-term care. It is one of two Medicare-certified nursing homes in Santa Fe, and it is also VA-contracted. It is located at: 

650 Galisteo Street 
Santa Fe, NM 87505 
Phone: (505) 984-8313 

Casa Real is owned by Genesis Healthcare, one of the largest nursing home providers in the nation. Genesis Healthcare has a known history of understaffing and underfunding its facilities while paying millions of dollars in salaries and bonuses to its top-level executives. The U.S. Justice Department has characterized Genesis Healthcare as an “unscrupulous provider.” 

The Risk of Nursing Home Abuse at Casa Real

Chronic understaffing threatens the quality of care and increases the risk of nursing home abuse. Nursing home staff are often overworked, undertrained, undercompensated, and underappreciated, resulting in worker frustration and burnout. This may result in staff lashing out at residents when they reach their breaking point. 

The Centers for Medicare and Medicaid Services (CMS) has given Casa Real a two-star rating for staffing, indicating the facility has lower-than-average staff levels.  

Residents at Casa Real receive just two hours and 59 minutes of direct nursing care per day, while nursing home residents across the nation receive an average of three hours and 45 minutes. Registered nurses (RNs) are the highest-trained nursing staff and are responsible for supervising resident care. 

While residents across the nation receive an average of 40 minutes of RN care daily, Casa Real residents receive just 24 minutes. The majority of direct care is provided by certified nursing assistants (CNAs). CNAs have the least training and often the poorest working conditions of all staff. As a result, they are the most likely to commit nursing home abuse.

Health Violations at Casa Real

Casa Real has had 61 inspections from 2005 to 2022. Compliant nursing homes are generally inspected once annually, indicating Casa Real has had more than 40 complaint inspections during this period.  

In 2022 alone, Casa Real underwent two complaint inspections in addition to the annual inspection and received 23 citations, significantly exceeding the national average of 8.5. Casa Real has paid $118,051 in federal fines and had one payment denial by Medicare and/or Medicaid in the last three years.

2022 Health Inspection

Surveyors identified numerous alarming deficiencies in the annual health inspection completed on March 23, 2022.

Neglect of Resident Comfort and Dignity

Casa Real failed to respect the dignity of residents by allowing at least two CNAs to refer to residents needing assistance eating as “feeders.” 

Surveyors found the following deficiencies in all three selected residents’ rooms, resulting in a citation for failure to provide safe, clean, and comfortable living quarters: 

  • Garbage not cleared from the rooms 
  • Excessive clutter on the floors
  • Paint coming off of walls 
  • Missing tiles in the bathrooms 
  • Unpleasant odors 

Casa Real failed to provide at least one resident with the correct size of adult briefs, resulting in the resident being expected to soil and/or wet the bed and wait for staff to clean it up after each incident, which staff failed to do. 

Casa Real failed to provide residents with foods that matched their preferences and accommodated allergies.

Neglect Care Planning

Casa Real neglected to provide appropriate care planning, which could have resulted in residents not receiving the care they needed. The deficiencies included failures to do the following: 

  • Develop and implement a care plan within 48 hours of admission 
  • Update care plans within seven days of the comprehensive assessments 
  • Develop and implement care plans to meet daily resident needs with measurable goals for the five residents reviewed

Neglect Resident Care

The facility failed to maintain the following professional quality standards, a repeat deficiency: 

  • Failure to regularly monitor blood glucose for at least six diabetic residents   
  • Placing a resident in the locked unit for convenience rather than meeting the resident’s needs 
  • Failure to follow doctor’s orders for weekly weight checks for an at-risk resident with declining weight  

Casa Real failed to provide assistance to a resident with showering according to the resident’s preferred frequency and schedule. This is a repeated deficiency. 

Casa Real failed to provide appropriate pressure ulcer care to at least two residents, resulting in at least one resident developing an unstageable pressure ulcer.   

Casa Real’s medication error rate is a shocking 23.08 percent, a rate that violates the CMS standard of less than five percent. Inspectors identified the following medication errors: 

  • Failure to discontinue medication as ordered by a physician 
  • Failure to refer a resident to a psychiatrist as ordered by the physician 
  • Administering an overdose of acetaminophen at a level known to cause liver damage 
  • Failure to timely administer ordered medication  
  • Failure to appropriately label and date medications, a repeat deficiency

Negligent Sanitation and Infection Control

Surveyors identified a repeat deficiency involving numerous unsanitary conditions in food storage and preparation areas, including the following: 

  • Expired, undated, and spoiled food  
  • Dirty food preparation surfaces, floors, and appliances 
  • Incomplete documentation of temperatures of food served to residents 
  • Improper sanitation of crockery and food storage containers 

Casa Real failed to implement infection control procedures, including failure to do the following: 

  • Adhere to COVID-19 infection prevention practices 
  • Keep clean and dirty laundry separate 
  • Use sufficient bleach in the COVID-19 kitchen sanitation buckets  
  • Sufficiently heat three-step washing sinks in the kitchen  
  • Replace sharps containers when full 

Complaint Inspections

During the last three years, seven complaints have resulted in citations for negligent care.  

During the complaint inspection on September 15, 2022, surveyors found that staff gave a drinking straw to a resident with difficulty swallowing in violation of the physician’s orders, which specified that straws increased the resident’s choking risk. 

The inspection also revealed that the facility failed to provide a resident with prescribed physical therapy to maintain his range of motion. 

The complaint inspection on July 21, 2022, revealed that Casa Real failed to provide a resident with prescribed anticoagulant medication for more than two weeks, and the resident suffered a stroke. Staff failed to notify the physician of early stroke symptoms for two days. The resident spent 42 days in the hospital and was left with multiple conditions and new requirements for two-person transfers with a Hoyer lift. 

Casa Real failed to provide at least five residents with assistance getting out of bed during the day.  

Casa Real staff regularly left an exit door open in the memory care unit, allowing residents to go outside unsupervised without staff knowledge. 

Quality of Care at Casa Real

CMS has rated Casa Real’s quality of care for long-term and short-term care as one star, which is much below average and the lowest rating available.   

Short-Stay Quality Concerns

Approximately 60.9 percent of short-stay residents at Casa Real experience improvements in their mobility, compared to 74.1 percent nationally and 67 percent statewide.   

Short-stay residents at Casa Real were more than three times as likely as the national average to experience falls resulting in major injury.  

As many as 12.4 percent of short-stay residents at Casa Real do not receive an assessment with functional goals included in their treatment plans. Nationwide, approximately 98.8 percent of short-stay residents receive this. 

Short-stay residents at Casa Real were less likely than the national average to experience improvements in their ability to care for themselves.


Approximately 27 percent of long-stay residents at Casa Real receive antipsychotic medications. This is significantly higher than the state average of 16.8 percent and the national average of 14.5 percent. This is a red flag that the facility improperly uses antipsychotic medications to sedate residents staff perceive as difficult. 

Long-stay residents are more than twice as likely as the national and state averages to have pressure ulcers (bedsores), with 17.6 percent of residents diagnosed with them. Bedsores in a nursing home almost always occur as a result of neglect. 

Casa Real residents are more likely than the state and national average to have had catheters inserted and left in their bladders. Indwelling catheters increase the risk of urinary tract infections and may be inappropriately used for staff convenience. 

Long-stay residents at Casa Real are more likely than the national average to experience declines in their mobility and independence. They are also more likely to lose excessive weight. They are less likely to receive a pneumonia vaccine. 

What to Do If You Suspect Abuse at Casa Real

If you suspect abuse has occurred at Casa Real, it is important to report it immediately. You do not have to have proof. A suspicion is justification to file a report. You should file a report with the following: 

Levin & Perconti Can Help With Your Nursing Home Abuse Case

If you or your loved one has experienced nursing home abuse at Casa Real, you may be entitled to substantial compensation. Levin & Perconti has helped abused nursing home residents get justice for more than three decades, and we consistently achieve outstanding results for our deserving clients such as the following: 

  • $4.1 million record-breaking jury verdict for an 85-year-old nursing home resident whose medications were mismanaged 
  • $2.7 million jury verdict for the family of a 67-year-old nursing home resident who died from a fall  
  • $2.3 million settlement for the family of an 88-year-old assisted living facility resident who died from infected bedsores  

We were one of the first law firms to stand up to negligent and abusive nursing homes. When you hire Levin & Perconti, you can count on us to fight for you to receive maximum compensation through a nursing home abuse lawsuit against Casa Real. Contact Levin & Perconti today for a free case review.