“Alison,” who requested SFR not use her real name because of ongoing litigation, has her own views on accountability—especially when it comes to Cathedral Rock. She describes her own experience as “unique because my mother didn’t die.”

Alison’s mother, who suffers from multiple sclerosis, spent only four days in Santa Fe Care Center, the other local nursing home owned by Cathedral Rock.

This past May, Alison’s mother was discharged from St. Vincent to Santa Fe Care Center for recovery but, on her second day there, nursing home staff called Alison late at night.

“They wanted to know what to do with my mother’s hair because they were going to give her a shower,” Alison says.

Medical records from the nursing home show that, at 10:30 pm on May 14, staff found Alison’s mother’s feeding tube on the floor and were planning to reattach it; Alison says no phone call ever mentioned this.

“If not successful, may transfer resident to [St. Vincent] to replace feeding tube,” the nursing home record reads.

That didn’t happen until late the next day, when Alison came down from her home in Los Alamos to visit and found her mother in critical condition.

At St. Vincent, doctors told Alison her mother needed emergency surgery.

According to the surgeon’s report, Alison’s mother’s sudden critical condition was caused by the nursing home’s failed attempt to reinsert her feeding tube.

When they resumed feeding her, instead of her stomach, the contents of the feeding tube were forced into her abdominal cavity. 

Alison didn’t hesitate. With the help of local lawyer Scott Voorhees, she filed suit against Santa Fe Care Center, and her mother was transferred out.

And into Casa Real.

Her mother is doing better, Alison says. But, she adds with frustration, “It’s the same damn company.”

That company, Cathedral Rock, has had its share of problems.

In January, Cathedral Rock pleaded guilty to Medicare and Medicaid fraud—billing patients despite rampant abuse, neglect and subpar care—in five of its nursing homes in Missouri. The company agreed to pay $1.6 million in criminal fines and civil settlement monies.

Then, in February, Casa Real was cited by the New Mexico Department of Health for failing to protect its residents from neglect and abuse and for improperly administering medication. The residents were declared to be in “immediate jeopardy,” prompting an immediate plan to retrain staff.

“Everything has been put back in place since then,” Casa Real’s current administrator, Renee Anderson, tells SFR. Casa Real, she says, is no longer out of compliance with any federal or state requirements.

“We definitely do a good job,” she adds. “We try to do everything we can for the resident.”

But according to numbers from the state ombudsman’s complaints database, Casa Real had by far more complaints (93 in the past year) than any other nursing home in the northeast region, which stretches from here to Las Vegas. Santa Fe Care Center, which is approximately the same size, logged only 56 complaints. Casa Real also reported the highest number of unresolved complaints: just more than 23 percent, while many facilities came in at zero.

Trotter, however, cautions against reading too much into those numbers because she often receives several complaints from the same person. And, according to federal law, ombudsmen must strive to resolve complaints “to the satisfaction of the complainant,” Trotter explains—so if a resident is just plain unhappy, it’s possible there’s nothing to be done.

“The high number of complaints reported for New Mexico indicates that the reporting system is working—signifying that citizens feel safe reporting to the state’s trained ombudsmen,” Emily Kaltenbach, the director of policy and planning at the state’s Aging and Long-Term Services Department, writes to SFR in an email. Of the 5,437 total complaints referred to ombudsmen statewide, Kaltenbach notes, “97% were resolved to the satisfaction of the complainant (resident, family member or facility staff).”

But these specific complaints are almost impossible to review. Except, of course, when they lead to lawsuits.