Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Ventanas De Socorro during CMS and state inspections, most recent first.
A resident's Significant Change MDS assessment did not accurately reflect their need for total assistance with bed mobility and failed to document both active autoimmune skin disease diagnoses. Staff interviews revealed gaps in communication and access to care information, and the facility did not follow its policy for comprehensive assessment review and validation.
Medications pending return to the pharmacy were found stored in open cardboard boxes on the floor of the DON's office, which was frequently left open and unsupervised. Staff interviews and observations confirmed that the medications were not kept in locked compartments as required, and the facility's own policy for secure storage and segregation of medications was not followed. Documentation showed that medications had been pending return for several months, and the proper process of using locked containers in the medication room was not consistently implemented.
A contracted agency CNA was not given access to the electronic documentation system to record care provided to a resident with complex medical needs. Instead, another CNA entered the information under her own name after verbally collecting details from the agency CNA, resulting in incomplete and inaccurate clinical records.
A resident with dementia, anxiety, and heart failure, who required assistance with mobility and self-care, was found to have her call light out of reach, contrary to her care plan and facility policy. Staff interviews confirmed that all personnel are responsible for ensuring call lights are accessible, but the device was observed wrapped around the bed rail and inaccessible, preventing the resident from communicating needs to staff.
A resident with multiple medical conditions, including autoimmune skin disease, did not have an updated care plan reflecting the need for two-person assistance with bed mobility or physician's orders for skin treatment. Staff were unaware of the resident's specific care needs, resulting in the resident experiencing pain during care. The care plan lacked documentation of key diagnoses, required interventions, and measurable objectives.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head injury. Despite facility policy requiring neurological checks for 72 hours after such incidents, staff did not document or consistently perform these assessments, citing the resident's transfer to the hospital and confusion about policy requirements. This resulted in a failure to provide care according to professional standards and the resident's care plan.
A resident with wounds, indwelling medical devices, and incontinence did not receive Enhanced Barrier Precautions as required, due to staff not being aware of EBP protocols, lack of PPE availability, and insufficient signage. Multiple staff members were unclear about EBP requirements, and leadership confirmed that recent training and consistent monitoring had not occurred, resulting in a breakdown of infection control practices.
Two residents with significant medical needs were found to have their call lights out of reach, despite facility policy and staff awareness requiring accessibility. One resident's call light was under a pillow and not locatable by the resident, while another's was hanging off a nightstand near the ground. Staff interviews confirmed the expectation that call lights be within reach, but observations showed this was not followed.
The facility did not complete required annual Employee Misconduct Registry (EMR) checks for a Van Driver and the ADON, as confirmed by record review and staff interviews. Although general abuse prevention and background check policies existed, there was no specific EMR policy, and the required annual checks were not performed as expected.
A resident with significant ADL needs and a history of orthopedic surgery did not have all showers or refusals properly documented, as required by facility policy. Staff interviews and record reviews revealed missing shower sheets, resulting in incomplete medical records and a failure to maintain documentation in accordance with accepted professional standards.
A resident received inadequate incontinence care from two CNAs who failed to perform proper hand hygiene and used incorrect cleaning techniques, increasing the risk of urinary tract infections. Despite acknowledging the importance of cleaning from front to back, the CNAs did not adhere to the facility's policy, which requires hand hygiene and the use of clean wipes for each stroke during perineal care.
A facility failed to maintain proper infection control when two CNAs did not perform hand hygiene before and after disposing of dirty wipes and briefs during perineal care for a resident. CNA A and CNA B were observed not washing hands between glove changes, contrary to facility policy. Interviews revealed a misunderstanding of hand hygiene protocols, with CNA B believing glove changes were sufficient. The ADON confirmed the need for hand hygiene but cited dignity concerns for not performing it between care steps.
A facility failed to maintain complete and accurate medical records for a resident with an injury to her left eyebrow and under her left eye. The resident, who was a fall risk with dementia, did not have hospital documentation included in her records, and there was no care plan addressing the injury. Staff interviews revealed that protocols for incidents and head injuries were not fully followed, and required documentation was missing.
A resident requiring a two-person assist for peri care was observed being assisted by only one CNA, who did not seek additional help. The CNA turned the resident on her side with wedges in place, contrary to the care requirements.
A deficiency was identified due to the absence of oxygen precaution signs outside the rooms of residents receiving oxygen therapy. A resident was observed with a nasal cannula but no sign, contrary to facility policy. Staff acknowledged the importance of these signs for safety and monitoring, but the responsibility for posting them was unclear. The Administrator minimized the fire risk due to a no-smoking policy, despite staff concerns about potential hazards.
A CNA in an LTC facility failed to perform proper hand hygiene during incontinent care for three residents, increasing the risk of infection. The CNA did not change gloves or wash hands during and after providing peri care, despite handling various items and redressing residents. This was observed in residents with complex medical conditions, including diabetes, dementia, and hemiplegia. Interviews confirmed the lapse in protocol, highlighting a breach in the facility's infection control policy.
A resident with a history of falls and requiring a two-person assist for peri care was left at risk when CNA-A performed the care alone, contrary to the care plan and facility policy. The DON and LVN-B confirmed the resident's high fall risk, and CNA-A admitted to not seeking help, assuming the surveyor present would suffice as a second pair of eyes.
Two residents in the facility did not receive appropriate treatment to prevent urinary tract infections due to improper peri-care by a CNA. The CNA used a single wipe multiple times, did not follow correct cleaning procedures, and failed to change gloves between tasks. These actions were against the facility's policy, which aims to promote cleanliness and prevent infection. The residents, both with significant medical conditions, were at risk of infections due to these deficiencies.
Inaccurate MDS Assessment and Omission of Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Significant Change Minimum Data Set (MDS) assessment accurately reflected the resident's current status. Specifically, the assessment did not document that the resident required total assistance of two persons for bed mobility, nor did it include both of the resident's active autoimmune skin disease diagnoses. The resident's medical record indicated a history of diabetes mellitus, osteoarthritis, rheumatoid arthritis, pemphigus vulgaris, and Stevens-Johnson Syndrome, with multiple skin lesions and impaired activities of daily living. However, the MDS only listed Stevens-Johnson Syndrome and reduced mobility, omitting pemphigus vulgaris. Interviews and record reviews revealed that staff were not consistently informed about the resident's care needs, and direct care staff did not always have access to information regarding the level of assistance required for activities of daily living. For example, a CNA reported not receiving a report at the start of the shift and lacking access to the electronic system to verify care requirements. The facility's policy required comprehensive review and validation of resident status during the MDS assessment process, but this was not followed, resulting in an inaccurate assessment.
Failure to Securely Store Medications Pending Pharmacy Return
Penalty
Summary
The facility failed to ensure that drugs and biologicals pending return to the pharmacy were stored securely in accordance with federal, state, and local laws. Multiple observations revealed that medication blister packets were kept in open cardboard boxes on the floor of the DON's office, which was frequently left open and unsupervised. The medications were visible from the entrance, and at various times, the office was unattended while non-nursing staff, such as a housekeeper, were present. Both the DON and the Administrator acknowledged that the medications were not stored in a locked cabinet and that the office door was not consistently secured. Interviews with nursing staff indicated that the standard practice was to place medications pending return to the pharmacy in locked containers within the medication room. However, the DON admitted that she was unsure how often medications were returned for credit and that some medications had been stored in her office since she began working at the facility several months prior. The Administrator confirmed that medications should not be left in the DON's office unless the door is locked, and that the proper procedure is to use locked containers in the medication room. Review of facility documentation showed that the last pharmacy pick-up slip was dated several months prior, and the Medication Return Logs indicated that medications had been pending return for an extended period. The facility's policy required that medications be securely stored and segregated until picked up by the pharmacy, but this was not followed. The failure to store medications securely in locked compartments as required was confirmed by both staff interviews and direct observation.
Failure to Provide Agency CNA Access to Electronic Documentation System
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who required transfer assistance, as required by accepted professional standards. Specifically, a contracted agency CNA was not given access to the electronic documentation system (Kiosk) to record the care provided to assigned residents in one of the facility's halls. As a result, the care delivered during the shift was not directly documented by the CNA who provided it, but instead was entered by another CNA who worked alongside him. This documentation was recorded under the second CNA's name after she verbally collected information from the agency CNA at the end of the shift. The resident involved had a complex medical history, including diabetes mellitus, osteoarthritis, rheumatoid arthritis, pemphigus vulgaris, and Stevens-Johnson syndrome, with multiple skin lesions and impaired activities of daily living. The resident was severely cognitively impaired, dependent on staff for most activities, and had ongoing issues such as chronic pain, incontinence, and pressure ulcers. The care plan required regular assessments and documentation of care, including wound care and assistance with activities of daily living. Interviews with facility staff and the agency CNA revealed that the CNA was not provided with access to the electronic record system because the Director of Nursing was unaware that he had been scheduled to work that shift. The agency CNA was not given instructions or assistance to document care, and the agency's scheduling coordinator confirmed that agency staff are typically given access to chart before their shifts. The lack of direct documentation by the assigned CNA resulted in incomplete and inaccurate clinical records for the resident.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by both the resident's care plan and facility policy. During an observation, the call device for a female resident with dementia, anxiety, and heart failure was found wrapped around the bed rail with the handle below mattress level, making it inaccessible. The resident was non-ambulatory and required partial to moderate assistance with mobility and self-care, according to her medical records and MDS assessment. Her care plan specifically included the intervention to keep the call light within reach at all times due to her high fall risk. Interviews with staff, including a CNA, LVN, DON, and the Administrator, confirmed that facility policy mandates call lights must always be within reach of residents. Staff acknowledged responsibility for ensuring call light accessibility and recognized that failure to do so could prevent residents from communicating their needs. The CNA could not recall recent training on call lights, and both the LVN and DON identified the call light in the surveyor's photo as being out of reach for the resident. The DON and Administrator reiterated that all staff, regardless of role, are responsible for checking call light placement before leaving a resident's room. The facility's policy and staff interviews consistently indicated that call lights are essential for residents to express their needs and request assistance. Despite this, the observed failure to keep the call light within reach for the resident placed her at risk of having unmet needs, as she was unable to contact staff when assistance was required. The deficiency was substantiated by direct observation, staff interviews, and review of the resident's care plan and facility policy.
Failure to Update and Implement Comprehensive Care Plan for Resident with Complex Skin Condition
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan with measurable objectives and timeframes for a resident with complex medical needs. Specifically, the care plan was not updated to reflect the requirement for two-person assistance with bed mobility due to pain caused by autoimmune skin disease, nor did it include physician's orders for treating the resident's autoimmune skin condition. The care plan also lacked documentation of the resident's diagnoses of pemphigus vulgaris and skin peeling, skin sensitivity, and the need for special precautions and treatments such as Prednisone and Silvadene. Observations and interviews revealed that the resident was alert and oriented but suffered from multiple medical conditions, including diabetes mellitus, osteoarthritis, rheumatoid arthritis, pemphigus vulgaris, and a history of Stevens-Johnson Syndrome. The resident had multiple skin lesions, scabs, and rashes, and required total assistance with activities of daily living (ADLs). Staff interviews consistently indicated that the resident needed two people for turning and repositioning in bed due to pain and skin fragility, and that a sheet was required to minimize direct contact with the skin. However, this level of assistance was not clearly documented in the care plan, leading to inconsistent care. On one occasion, a CNA who was not given a proper report or access to the electronic care system provided care to the resident alone, resulting in pain and discomfort for the resident during bed mobility. The CNA was unaware of the need for two-person assistance and the resident's specific care requirements. Family and staff interviews confirmed that the resident experienced significant pain when moved by only one person. The MDS nurses acknowledged that the care plan did not accurately reflect the resident's current needs or physician's orders, and that information was not consistently gathered from all relevant staff.
Failure to Perform and Document Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan following an unwitnessed fall. The resident, who had a history of dementia, cognitive decline, and previous falls, experienced an unwitnessed fall resulting in a laceration and hematoma to the head. According to the facility's fall management and neurological check policies, neurological checks were required to be performed and documented for 72 hours following such an incident. Despite these requirements, there was no documentation of initial or ongoing neurological checks for the resident after the fall. Interviews with nursing staff and the DON revealed that while some neurological assessments may have been performed, they were not documented as required by policy. Staff indicated that neurological checks were not completed or documented because the resident was sent to the hospital, and there was confusion regarding whether checks should continue upon the resident's return without a physician's order. The facility's own policies, however, specified that neurological checks should be performed and documented after unwitnessed falls, regardless of hospital transfer, unless otherwise directed by a physician. Record reviews confirmed the absence of neurological check documentation in both the neurological checks binder and the resident's progress notes. Multiple staff interviews acknowledged the lapse in following policy, and the DON confirmed that staff did not adhere to the facility's procedures for neurological monitoring after the fall. The failure to perform and document neurological checks as required constituted a deficiency in providing care according to professional standards and the resident's care plan.
Failure to Implement Enhanced Barrier Precautions and Maintain PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors, including wounds, indwelling medical devices, and incontinence. The resident had a complex medical history, including pemphigus vulgaris and Stevens-Johnson Syndrome, resulting in multiple skin lesions, a pressure ulcer, and a feeding tube. Despite physician orders and care plans indicating the need for EBP, staff did not consistently implement these precautions during high-contact care activities. Multiple interviews with staff revealed a lack of awareness and understanding of EBP, with several CNAs and nurses stating they only used gloves and did not recognize which residents required EBP. PPE such as gowns and gloves were not readily available in the designated resident halls, and signage indicating EBP requirements was either absent or limited to small CDC pocket guides, which staff often did not notice. Some staff reported not receiving orientation or training on EBP, and there was confusion between EBP and isolation/contact precautions. Additionally, supply checks for PPE were inconsistent, with empty containers and drawers observed during the survey. Leadership interviews confirmed that there had been no recent staff training on EBP, and monitoring of PPE availability was not reliably performed. The infection control policy required clear signage, accessible PPE, and staff education, but these measures were not fully implemented. The deficiency was identified through observations, interviews, and record reviews, demonstrating a systemic failure to follow established infection control protocols for residents at risk of MDRO transmission.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in a deficiency related to the reasonable accommodation of resident needs and preferences. For one resident, who had diagnoses including hypertension, congestive heart failure, Parkinson's Disease, dementia, and diabetes, the call light was found underneath the pillow at the head of the bed, out of the resident's reach. This resident was dependent on staff for most activities of daily living, including toileting and transfers, and had a history of falls. The care plan specifically directed that the call light should be kept within reach at all times. During observation, the resident was unable to locate the call light, and an LPN had to retrieve it from under the pillow, confirming it was not accessible as required. Another resident, with diagnoses of diabetes, hypertension, congestive heart failure, and chronic kidney disease, was observed asleep in bed with the call light hanging off the nightstand close to the ground, also out of reach. This resident required partial to moderate assistance with daily activities and used a wheelchair. Staff interviews, including those with the DON, NP, and Administrator, confirmed that facility policy and staff expectations required call lights to be within reach of residents at all times to ensure accessibility to staff assistance. Facility policy reviewed indicated that staff must ensure call lights are placed within the resident's reach when leaving the room. Despite this policy and staff awareness of the requirement, observations and interviews confirmed that the call lights for both residents were not accessible, constituting a failure to reasonably accommodate their needs and preferences as required.
Failure to Conduct Required Annual EMR Checks for Staff
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent abuse, specifically by not conducting required annual Employee Misconduct Registry (EMR) checks for two employees, the Van Driver and the Assistant Director of Nursing (ADON). Record reviews showed that the annual EMR checks for both employees, which were due, had not been completed. Interviews with the Administrator and HR confirmed that EMR checks are required upon hire and annually, and that the purpose of these checks is to ensure staff eligibility to work at the facility. Further review of facility policies revealed that while there was a general policy on abuse, neglect, exploitation, or mistreatment, and a background check policy, there was no specific EMR policy in place. The Administrator stated that corporate had informed him there was no EMR policy and that they followed state guidelines. HR acknowledged responsibility for ensuring EMR checks were completed and recognized that failure to do so could result in ineligible staff working at the facility, potentially placing residents at risk.
Failure to Accurately Document Resident Showers in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, specifically regarding the documentation of showers provided or refused. Record reviews showed that the resident, who was admitted with multiple medical conditions including osteopenia, right hip arthroplasty, and a left femoral neck fracture, required substantial assistance with activities of daily living (ADLs) such as bathing. The care plan indicated the resident was at risk for pressure ulcers and required regular hygiene to maintain dignity and prevent complications. Despite the established schedule for showers and the use of shower sheets for documentation, two shower sheets were missing for days when the resident either received or refused a shower. Interviews with the DON, Administrator, and CNAs confirmed that showers or refusals were expected to be documented on the shower sheets, but staff could not account for the missing documentation. The facility's own policy required nursing staff to record care and treatment, including showers, in accordance with regulatory requirements. The lack of documentation was acknowledged by multiple staff members, including the DON, Administrator, and CNAs, who stated that it was their responsibility to ensure showers and refusals were properly recorded. The absence of these records resulted in incomplete and potentially inaccurate medical records for the resident, as required by professional standards and facility policy.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate incontinence care for a resident, leading to potential risks for urinary tract infections. During an observation, two CNAs provided incontinence care to a resident without performing proper hand hygiene. CNA A and CNA B were observed changing gloves without washing their hands, and CNA A cleaned the resident's genital area incorrectly, wiping from rectum to perineum instead of the recommended front to back method. This improper technique can lead to contamination and increase the risk of infections. Interviews with the CNAs and other staff members, including the ADON and Wound Care LVN, revealed a lack of adherence to the facility's policy on hand hygiene and perineal care. The CNAs acknowledged the importance of cleaning from front to back to prevent infections but failed to follow this practice. The ADON and Wound Care LVN emphasized the necessity of hand hygiene before and after perineal care, yet the CNAs did not perform hand hygiene between glove changes. The facility's policy requires staff to perform hand hygiene and use clean wipes for each stroke during perineal care, which was not followed in this instance.
Inadequate Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during perineal care for a resident. CNA A and CNA B did not perform hand hygiene before and after disposing of dirty wipes and briefs, and before applying new briefs on the resident. This lapse in protocol was observed during a care session, where CNA B disposed of a dirty brief and gloves without washing hands before donning new gloves. Similarly, CNA A cleaned the resident's genitalia and buttocks without performing hand hygiene between glove changes. Interviews with the CNAs and other staff members revealed a lack of adherence to proper hand hygiene practices. CNA A acknowledged the risk of transmitting bacteria and viruses due to inadequate hand hygiene, while CNA B believed that changing gloves was sufficient to maintain cleanliness. The ADON confirmed that hand hygiene should be performed before and after perineal care, but not in between, citing concerns about resident dignity. The facility's policy requires hand hygiene before and after glove changes, but the ADON could not recall the last in-service training on this topic.
Incomplete Medical Records for Resident Injury
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who had an injury to her left eyebrow and under her left eye. The resident, who had a history of age-related physical debility, ataxic gait, and dementia, was admitted to the facility and was identified as a fall risk with no safety awareness. Despite this, the facility did not include hospital documentation related to the resident's injury in her medical records. Additionally, there was no care plan addressing the injury, and the progress notes lacked follow-up documentation on the condition of the bruise, including its size or healing stage. Interviews with facility staff revealed that the protocol for incidents involving injuries of unknown origin was not fully adhered to. The Assistant Director of Nursing (ADON) acknowledged the absence of hospitalization documentation, which was still pending at the time of the investigation. Furthermore, a Licensed Vocational Nurse (LVN) stated that the protocol for head injuries included neurological checks and monitoring vital signs, but there was no evidence of such follow-up in the resident's records. The facility's policy required documentation of the resident's condition every shift for three days following an incident, which was not observed in this case.
Inadequate Assistance During Peri Care
Penalty
Summary
During an observation, a deficiency was noted involving a resident named Lucina who required peri care. The care was provided by a CNA who was supposed to have assistance from another person, as the resident was designated as needing a two-person assist. However, the CNA did not request help and proceeded to turn the resident on her side with wedges in place, towards the wall, while the bed was locked. This action was contrary to the resident's care requirements, as only one person was assisting instead of the required two.
Failure to Post Oxygen Precaution Signs
Penalty
Summary
The deficiency involves the failure to post oxygen precaution signs outside the rooms of residents receiving oxygen therapy. Resident #79 was observed wearing a nasal cannula without an oxygen sign posted outside her room. The facility's policy requires that oxygen precaution signs be placed on the doors of residents receiving oxygen to ensure safety and awareness among staff and visitors. Staff members, including a CNA and an LVN, acknowledged the importance of these signs in preventing potential fire hazards and ensuring that staff remember to check residents' oxygen levels. Despite the facility's no-smoking policy, the absence of oxygen signs poses a risk, as visitors may unknowingly bring fire hazards into the room. The Director of Nursing (DON) and the Administrator both stated that the responsibility for posting these signs lies with the administration and nursing teams. However, there was a discrepancy in their understanding of the potential risks, with the Administrator downplaying the fire hazard due to the non-smoking policy. The lack of signage could lead to staff not being aware of the need to monitor oxygen levels, and visitors not being aware of the fire risk associated with oxygen use.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene practices of a CNA during incontinent care for three residents. The CNA did not change gloves or perform hand hygiene during and after providing peri care to the residents, which is a critical step in preventing the transmission of infections. This lapse in protocol was observed during care for Resident #4, Resident #10, and Resident #52, placing them at risk of infection. Resident #4, a male with multiple medical conditions including Type 2 diabetes and atrial fibrillation, required extensive assistance with toileting. During care, the CNA did not remove gloves or perform hand hygiene after peri care, and proceeded to touch the resident's call light and clean his face with the same gloves. Similarly, Resident #52, who was cognitively intact but dependent on staff for toileting due to conditions like hemiplegia and a history of stroke, received care without the CNA changing gloves or performing hand hygiene. The CNA handled oxygen tubing and other items with contaminated gloves, further increasing the risk of cross-contamination. Resident #10, a female with a complex medical history including respiratory failure and dementia, was also subjected to improper hand hygiene practices. The CNA did not change gloves or perform hand hygiene throughout the peri care process, even when redressing the resident. Interviews with the CNA and the Director of Nursing (DON) confirmed the failure to adhere to hand hygiene protocols, acknowledging the potential for cross-contamination and infection spread among residents. The facility's policy on hand hygiene clearly outlines the need for handwashing before and after resident contact, which was not followed in these instances.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, leading to a deficiency in care. Resident #10, a female with a history of dementia, syncope, convulsions, hemiplegia, aphasia, cerebral infarction, and a history of falls, required a two-person assist for peri care due to her high risk for falls. Despite this requirement, CNA-A performed peri care alone, without seeking assistance, even though the resident had previously fallen during such care. This action was contrary to the care plan and the facility's fall management policy, which mandated a two-person assist for this resident. Interviews with the Director of Nursing (DON) and LVN-B confirmed that the resident was at high risk for falls and required a two-person assist during peri care. The DON acknowledged that the failure occurred because CNA-A did not call for help, despite knowing the resident's care requirements. CNA-A admitted to not asking for assistance, mistakenly assuming the state surveyor present would serve as a second pair of eyes. This oversight in following the care plan and facility policy placed the resident at risk of another fall during care.
Improper Peri-Care and Incontinence Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents who were incontinent of bladder. Observations revealed that CNA-A did not perform proper peri-care for these residents. For one resident, CNA-A used a single wipe multiple times and did not follow the correct procedure for cleaning the foreskin. For another resident, CNA-A performed peri-care from back to front, used the same wipe multiple times, and did not change gloves between cleaning after a bowel movement and performing catheter care. These actions were contrary to the facility's policy, which requires staff to perform perineal care with each bath and after each incontinent episode, following standard precautions to promote cleanliness and prevent infection. Resident #4, a male with medical diagnoses including Type 2 diabetes and atrial fibrillation, required extensive assistance with toileting. Resident #52, also a male, had diagnoses including Type 2 diabetes, dementia, and retention of urine, and was dependent on staff for toileting. Both residents were at risk of infections due to improper incontinent care and hand hygiene. Interviews with CNA-A and the DON confirmed the improper techniques used during peri-care, which could lead to cross-contamination and infections. The facility's policy and procedures were not adhered to, resulting in a deficiency in the care provided to these residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Socorro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Giles Nursing And Rehabilitation Center | 1.9 mi | — | 5 | 0 |
| Oasis Nursing & Rehabilitation Center | 3.2 mi | — | 0 | 0 |
| Pebble Creek Nursing Center | 5.9 mi | — | 8 | 0 |
| El Paso Health & Rehabilitation Center | 6.3 mi | — | 0 | 0 |
| Vista Hills Health Care Center | 6.9 mi | — | 16 | 1 |
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