Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
Failure to Provide Foot Care and Podiatry Access: A resident with severe cognitive and physical impairment, bed confinement, and dependence for personal care had markedly long toenails and no clear follow-through for podiatry services. Staff gave inconsistent accounts of who was responsible for nail care and arranging podiatry, and hospice staff stated the family was responsible for payment while the resident’s focus was on wounds rather than nail care.
MDS assessments did not accurately reflect two residents’ status. One resident with CVA and dementia was coded as having adequate hearing despite care plan documentation of right-sided hearing difficulty. Another resident admitted after a trimalleolar fracture with an external fixator had an MDS that omitted surgical wound care and the external fixator, even though daily wound treatment was ordered and provided. The MDS nurse stated the wound care was omitted because it would increase reimbursement and said the resident’s hearing issue had not been reported.
Care plans for two residents did not fully reflect their wound care and device-related needs. One resident with CKD, DM, and leg wounds had a care plan that addressed only one leg ulcer and omitted the other wound, while another resident with a trimalleolar fracture, external fixator, and a left ankle blister had a care plan that did not include the wound care or the external fixator details. Staff interviews confirmed the care plans were expected to identify wound sites, monitoring needs, and equipment, but the documented plans were not specific.
A facility failed to ensure that residents who needed help with ADLs received needed grooming and hygiene assistance. A female resident who was dependent for bathing and oral hygiene was observed with chin hair and said she wanted it shaved if offered. Another female resident with hemiplegia, dementia, and hospice services was observed with a mustache and chin hair and said staff had not offered shaving during recent showers. A male resident with dementia and left hemiplegia was observed with long, dirty fingernails despite requiring substantial/maximal assistance with personal hygiene.
Improper Disposal of Razors in Sharps Containers: Two residents with dementia-related cognitive impairment had disposable shaving razors observed sitting in the slot of the sharps container in their rooms. CNA, RN, and DON interviews confirmed razors were to be fully disposed of in the sharps bin and not left in the slot, and the facility policy identified sharps as biohazardous waste.
A resident with chronic respiratory failure, a resident with COPD, and a resident with CHF and chronic respiratory failure were receiving oxygen therapy, but staff did not maintain oxygen equipment as described. One resident’s concentrator filter had visible dust and lint, another resident’s nasal cannula was left on top of the concentrator instead of being stored in a plastic bag, and a third resident’s concentrator filter was noticeably dusty with no date of last service. Staff interviews stated cannulas were to be kept bagged when not in use and filters were to be cleaned weekly.
Food Storage, Labeling, and Hygiene Deficiencies: Surveyors observed spoiled and improperly stored food in the kitchen, including molded tomatoes, uncovered carrots, expired pudding sherbert, unlabeled prepared items, and diced turkey left on the counter. The refrigerator/freezer temp log was completed in advance, grease traps were dirty, and a dietary aide was observed working without proper facial hair restraints. Interviews and policy review confirmed required practices for labeling, safe thawing, accurate logs, and hair/beard restraints.
Steam Table Well Not Maintained in Working Order: A cook was observed serving lunch from a steam table with one well not operational, as the knob was not lit, the well was not hot, and no steam was present. The cook, Dietary Mgr, and Maintenance Dir confirmed the issue had been ongoing for weeks, with verbal reports and repair attempts that did not permanently fix the problem. Staff used other equipment to hold food, and a Dietary Aide stated the missing well could affect food temperature and delay meal service.
A resident with dementia and dysphagia who required supervision or touching assistance with eating was fed while a CMA stood over him instead of assisting at eye-level. The CMA acknowledged this was not correct and said it was a dignity issue, while the RN and DON stated staff were trained to feed residents while sitting and at eye-level and that nursing staff were responsible for monitoring meal service.
A nurse documented wound care as completed for one resident even though it was not performed, and a wound care nurse left another resident’s ankle dressing undated and unlabeled. The residents had wound orders related to chronic leg ulcers and a fracture-related ankle blister, and staff interviews confirmed the missed treatment and the unlabeled dressing.
Improper Foley Bag Placement and Tubing Drainage: Two residents with indwelling Foley catheters were observed with catheter care issues. One resident’s Foley bag was on the bed rail contacting the floor, and another resident’s Foley tubing had urine and white film pooling in the line and was not draining properly into the bag. Staff interviews confirmed that the bag should not be on the floor and that poor drainage was not acceptable because it could lead to infection or obstruction.
Unlabeled Enteral Feeding: A resident with CVA, dysphagia, and DM received nutrition via a gastric tube, but the enteral feeding bag was observed without a name or date label while infusing at bedside. RN, ADON, and DON interviews confirmed staff were responsible for labeling tube feedings with initials and the date, and the facility policy did not address labeling or dating.
Inaccurate wound care documentation: A resident with CKD, DM2, and a venous leg ulcer had daily wound treatment ordered, but an RN marked the care as completed even though he later admitted he did not provide it. The resident and family reported the wound care was missed, and the DON confirmed the charted treatment did not match what occurred. The facility policy required complete and accurate clinical documentation.
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.
Failure to Provide Foot Care and Podiatry Access
Penalty
Summary
The facility failed to provide proper foot care and access to podiatry services for a resident who was dependent for personal care and had severe cognitive and physical impairment. The resident’s record showed diagnoses including severe weakness, weight loss/failure to thrive, muscle wasting, functional quadriplegia, bed confinement, encephalopathy, anxiety, and severe muscle weakness from critical illness. The MDS reflected a BIMS score of 0, and the resident had impairment in one upper extremity and both lower extremities. The care plan indicated the resident required substantial to maximal assistance with putting on and taking off footwear and with personal hygiene, and the physician orders included a podiatrist appointment order. During observation, the resident was noted to have toenails approximately 3 centimeters long while the fingernails were trimmed. Staff interviews showed inconsistent understanding of who was responsible for nail care and arranging podiatry services. An RN stated nursing rounds were done frequently and that nursing would make a wound care order and a podiatry order if needed, while also stating administration followed up when there was an order. A CNA stated that nurses were responsible for nail care and that CNAs reported concerns to nursing, but CNAs did not document nail care on the plan of care. Another CNA stated nurses and the podiatrist were responsible for nail care and that CNAs told nurses when residents needed nail care. The DON stated the nurse would print the podiatry information for the transportation person to make the appointment, and that the nurse was responsible for the hall to make sure it was getting done. The DON also stated that for hospice residents, hospice was responsible for podiatry, while the CNAs at the facility should still let staff know if a resident needed care. Hospice staff stated the family was responsible for paying the podiatrist and that the resident was a new admission, and one hospice RN stated the focus was on wounds and not nail care. The Administrator stated the process for podiatry on hospice patients was not clear and that if the resident got care, it would be voiced by anyone in the facility or hospice. The facility policy stated leadership would provide podiatry services for nail disorders and preventive foot care when indicated, and that the facility would assist residents in obtaining services if they were unable to choose their own podiatrist.
MDS Did Not Accurately Reflect Hearing Status and Wound Care
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected Resident #70’s hearing status. Resident #70 was admitted with diagnoses including cerebrovascular accident, unspecified dementia without behavioral disturbance, essential hypertension, and atherosclerotic heart disease. The MDSs reviewed coded the resident in Section B as having adequate hearing and not using a hearing aid, while the care plan dated 2/17/2026 identified difficulty understanding others related to hard of hearing on the right side and included interventions such as repeating phrases, speaking clearly, and adjusting tone as needed. The facility also failed to accurately document Resident #79’s surgical wound care and external fixator on the MDS. Resident #79 was admitted after a fall at home that resulted in a left trimalleolar fracture requiring a closed reduction and external fixation. The comprehensive MDS identified fractures and other multiple trauma and presence of other medical devices as the primary reason for admission, but Section M did not include surgical wound care or pressure ulcer wound care. The care plan revision dated 02/09/2026 did not include the resident’s wound care or external fixator, although the resident had an order for daily treatment of a left medial ankle blister with normal saline or wound cleanser, betadine, and open to air. During interview, the MDS nurse stated Resident #70 never reported hearing difficulty and that if a hearing impairment were identified, the resident would be evaluated by SLP and referred to a specialist. She also stated that if there was a discrepancy in the MDS, she would speak to the DON and Social Worker to further evaluate the concern and update the care plan and MDS accordingly. For Resident #79, the MDS nurse stated the purpose of including the surgical wound care was to increase reimbursement as it was a service provided by the facility, and that not including it would not affect the resident. The facility policy stated each assessment must represent an accurate picture of the resident’s status during the observation period and that all resident needs and strengths are to be addressed within the MDS assessment.
Care plans omitted wound care and external fixator details
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for two residents who had identified wound care and device-related needs. Resident #26 was admitted with chronic kidney disease, type II diabetes mellitus, and wounds on both legs, and was cognitively intact with a BIMS score of 15. Her care plan addressed a left lower leg venous ulcer, but it did not include the right lower leg wound that was identified in the report. Wound care orders and wound management documentation showed ongoing treatment for the left lower lateral distal leg wound, including cleansing, topical medications, dressings, and Tubigrip compression. Resident #79 was admitted after a fall at home that resulted in a left trimalleolar fracture requiring a closed reduction and external fixation. Her history and physical also noted diabetes mellitus, a left eye prosthetic, and legal blindness in the right eye, and her BIMS score was 15. The comprehensive MDS identified fractures and other multiple trauma and presence of other medical devices as active diagnoses, but the skin conditions section did not include surgical wound care or pressure ulcer wound care. The care plan dated 02/09/2026 did not include the resident's wound care or the external fixator, although it did note fall risk related to the external fixator with general interventions such as keeping the call light and personal items within reach and keeping the room clutter free. The baseline care plan for Resident #79 noted wound care but did not specify the site or frequency of treatment. The wound care order directed daily treatment for a left medial ankle blister with cleansing, betadine, and leaving it open to air. During interviews, RN I stated surgical incisions and equipment were to be added to the care plan so staff would know the site, what to monitor, and the type of equipment. The MDS nurse stated the wound care related to the external fixator was not on the care plan and that care plans were to be specific to the resident's needs. The DON stated nursing staff were responsible for the basic care plan and that the purpose of the care plan was to make staff aware of residents' needs, including wound care and the external fixator.
Failure to Provide Needed Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain grooming and personal hygiene for three residents reviewed. Resident #4, a female with generalized muscle weakness and type II diabetes mellitus, was completely dependent for showering/bathing and oral hygiene per the MDS, and her care plan required one staff member to assist with personal hygiene. On observation and interview, she was seen with hair on her chin and stated staff assisted with showers and personal grooming every other day, but she was aware of the facial hair and would like it shaved if offered by staff. Resident #7, a female with hemiplegia and hemiparesis affecting the right dominant side, cerebral infarction, unspecified dementia, and hospice services, was coded on the MDS as needing partial/moderate to substantial/maximal assistance with ADLs including dressing, bathing, toileting, and oral hygiene. Her care plan required assistance with ADLs due to hemiplegia, hemiparesis, and dementia, and stated she was to be kept clean and comfortable. On observation, she had a mustache and chin hair measuring approximately a quarter to half an inch in length. During interview, she stated she did not like having facial hair and said staff and hospice had not offered to shave it during recent showers. She later stated staff had been short staffed and limited in providing shaving services, and that she had her own personal electric shaver in her room that staff could use. Resident #11, a male with depression, dementia, and left hemiplegia, had a BIMS score of 10 and required substantial/maximal assistance with personal hygiene per the MDS and care plan. On observation, he was in bed resting with his eyes closed, and his nails were long and untrimmed, approximately 1 inch, with black and dark debris under the fingernails of both hands. Staff interviews indicated residents were monitored for nails and facial grooming during showers, shower sheets were reviewed by nurses, and if residents refused grooming, staff were to notify the nurse; however, the observations showed the grooming and nail care needs were not met for the residents identified.
Improper Disposal of Razors in Sharps Containers
Penalty
Summary
The facility failed to keep the resident environment as free from accident hazards as possible for two residents with dementia-related cognitive impairment. Resident #24 had a diagnosis of dementia, a BIMS score of 05 indicating severe cognitive impairment, and a care plan noting memory/recall problems with interventions to redirect the resident when entering unsafe areas. Resident #29 also had a diagnosis of dementia, a BIMS score of 10 indicating moderate cognitive impairment, and a care plan noting moderate cognitive memory/recall problems with similar redirection interventions. During observation on 2/15/26 at 12:50 p.m., two disposable shaving razors were found sitting in the slot of the sharps container in Resident #24's room, and two disposable shaving razors were found sitting in the slot of the sharps container in Resident #29's room. In interviews, CNA N, RN I, and the DON stated that razors were to be disposed of in the sharps container and not left in the slot, and that staff were responsible for ensuring sharps were fully placed in the bin. The facility policy on biohazardous waste identified sharps as discarded sharps including hypodermic needles, syringes, and scalpel blades.
Oxygen Equipment and Cannula Storage Not Maintained
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who were receiving oxygen therapy. For Resident #23, record review showed diagnoses of vascular dementia and chronic respiratory failure with hypoxia, a BIMS score of 3, and an order for 2 liters per minute of oxygen. During observation, the resident’s oxygen concentrator was found in the room with the air filter exposed and labeled as replaced on 8/18/2021, with visible lint and dust buildup on the filter. The resident was asleep at the time of the observation and could not be interviewed. For Resident #62, record review showed a diagnosis of COPD, a BIMS score of 11, and an order for oxygen at 2-5 liters per minute via nasal cannula as needed. The care plan identified the resident as at risk for respiratory distress and included administering oxygen as ordered. During observation, the resident’s nasal cannula was sitting on top of the oxygen concentrator and was not stored in a plastic bag while not in use. For Resident #67, record review showed diagnoses of CHF, anemia of chronic disease, and chronic respiratory failure with hypoxia, along with oxygen therapy orders and care plan interventions related to respiratory status and oxygen use. During observation, the resident’s oxygen concentrator had a noticeably dusty air filter with no date of last service. Interviews with staff indicated that nasal cannulas were supposed to be stored in a plastic bag when not in use and that oxygen concentrator filters were to be cleaned weekly, but the observations showed the filter was dusty and the cannula was not stored as described.
Food Storage, Labeling, Thawing, and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an initial kitchen tour on 02/15/2026, surveyors observed 23 pudding sherbert items on cart shelves in the walk-in freezer with a preparation date of 2/8/2026 and a use-by date of 2/10/2026. At that same time, other cart shelves holding desserts and cold sides for upcoming meal services did not have preparation or use-by labels. A bag of approximately 15 carrots was found on a shelf without an opened and use-by label and was exposed to air, and 4 tomatoes with visible mold were observed touching other tomatoes without visible mold. Additional kitchen observations on 02/15/2026 found large frozen ice crystals on boxes of food on shelves directly under the fan and condenser, a plastic baggie of chile rellenos without a use-by date, and a bag of breaded mozzarella marked with a use-by notation but no date. The temperature log for the refrigerator and freezer had the afternoon temperature completed in advance by [NAME] C. A bag of diced turkey cubes was left on the counter near the walk-in refrigerator entrance and was cool to touch but not frozen. The grease traps above the grill and fryer were visibly dirty with grease and dust, while the log reflected they had been cleaned on 2/13/2026. During dining and meal service observations on 02/15/2026, 02/16/2026, and 02/17/2026, Dietary Aide K was observed preparing food, handling food, or working in the kitchen without properly restraining facial hair from his beard, sideburns, and mustache. In interviews, Dietary staff stated that hairnets and beard nets were required in the kitchen, that logs were to be signed when completed and not in advance, that spoiled or unlabeled food should be discarded, and that thawing poultry should be kept on ice, in the refrigerator, or in the freezer when not actively being used. Record review showed the facility's Nutritional Policies and Procedures required appropriate hair restraints, safe thawing methods, and refrigerated ready-to-eat TCS foods to be covered, labeled, and dated with a use-by date.
Steam Table Well Not Maintained in Working Order
Penalty
Summary
The facility failed to maintain the steam table in safe operating condition when the furthest right well was not operational and was still being used to hold food for breakfast and lunch. During an observation on 2/15/2026 at 12:04 PM, the cook was serving lunch from the steam table with 4 of 5 wells filled with food, and the fifth well was not hot to touch, did not emit steam, and its electric knob was not illuminated. The cook and the Dietary Manager confirmed that the fifth well was not working. During interview, the cook stated the steam table well had not been working for about 2 months after the previous shift left it on all night, and she described brown charring marks and white spots that took hours to scrub clean. She stated she had reported the problem to the Dietary Manager by word of mouth on 12/31/2025 and that, because the steam table had not been fully operational, she had to use the steamer and oven to accommodate the missing well. She stated holding food in the oven affected the food's appearance, taste, and texture, and she identified the Dietary Manager as responsible for maintaining, documenting, and reporting faulty equipment to the Administrator or Maintenance Director. The Maintenance Director stated he was responsible for maintaining the building and contacting vendors when specialty qualification was required, and that staff reported equipment problems verbally because there was no documentation completed. He stated he was notified of the steam table about 3 weeks earlier by the Dietary Manager and that he had repaired it, but it became faulty again in the second week of February 2026. The Dietary Manager stated the steam table well had not been operational for 2 to 3 weeks, that he had notified the Maintenance Director verbally when it initially broke, and that the repair did not permanently resolve the issue. He also stated the facility used other equipment to keep food warm and that the steam table not being fully operational had not affected residents, while a Dietary Aide stated the missing well could prevent food from being held at the appropriate temperature and could delay meal service.
Dignity Failure During Feeding Assistance
Penalty
Summary
The facility failed to treat one resident with respect and dignity when CMA H fed Resident #14 while standing instead of assisting at eye-level. Resident #14 was an [AGE]-year-old male with a history of dementia and dysphagia. His MDS showed he was unable to complete the BIMS interview, had short-term and long-term memory problems, was severely impaired for daily decision making, and required supervision or touching assistance with eating. His care plan directed that one staff member assist with eating through supervision or touching assistance. On 02/15/2026, an observation showed CMA H feeding Resident #14 a spoon of Jello while still standing. During interview, CMA H stated she was not assigned to feed residents but was helping the CNAs, and she acknowledged that standing while assisting with feeding was not correct and was a dignity issue. RN I stated staff were to assist residents with feeding while sitting down and at eye-level, and the DON stated staff were trained to feed residents while sitting and that nurses were responsible for monitoring the dining room to ensure residents were assisted correctly. The facility policy stated it provides care and services to ensure residents' abilities in ADLs do not diminish and that necessary care is provided to residents unable to carry out ADLs on their own.
Missed wound care and unlabeled dressing
Penalty
Summary
The facility failed to ensure that wound care was provided and documented in accordance with orders and that wound dressings were properly labeled for two residents. One resident had chronic kidney disease, type II diabetes mellitus, and wounds on both legs. Her care plan directed staff to provide wound care as ordered using aseptic technique, and her wound orders included daily treatment to the left lower lateral distal leg. The wound care administration record showed the treatment marked as completed on 01/31/2026, but RN O later stated she did not provide the wound care that day because she did not have the needed Normal Saline and did not notify the DON or other staff. A second resident was admitted after a fall that resulted in a left trimalleolar fracture and had a left medial ankle blister with an order for daily wound treatment. During observation, the resident’s left ankle dressing was found not dated or labeled with staff initials. The resident was cognitively intact with a BIMS score of 15. The wound care nurse stated she forgot to label the dressing, and other nursing staff stated dressings were expected to be dated and initialed after wound care was completed. The resident’s care plan did not include the wound care or external fixator, and the MDS did not include surgical wound care or pressure ulcer wound care. The report also states that the facility’s wound care policy did not contain information regarding wound care labeling expectations. The deficiencies were identified through record review, observation, and staff interviews, including confirmation from RN O that wound care had been documented as completed when it was not actually performed.
Improper Foley Bag Placement and Tubing Drainage
Penalty
Summary
The facility failed to ensure appropriate catheter care and infection prevention for two residents with indwelling Foley catheters. Resident #72, a female with diagnoses including generalized weakness, UTI, dementia with behavioral disturbances/anxiety, obstructive reflux uropathy, and chronic kidney disease, was observed in bed with her Foley bag on the bed rail contacting the floor. In a later observation, the Foley bag was again seen contacting the floor and laying nearly flat. Resident #72 was unable to participate in interview and could not be redirected. Resident #67, a female admitted with diagnoses including chronic congestive heart failure, age-related physical debility, acute renal failure, and obstructive uropathy, had an indwelling Foley catheter ordered for obstructive and reflux uropathy. Her care plan identified the catheter and noted a prior UTI. During observation, her Foley tubing was seen with urine and white film pooling in the line and not properly draining into the Foley bag because the tubing was below the height of the bag. A later observation showed the same condition, with urine and white film still pooling in the tubing and not draining properly. During interview, Resident #67 stated she had experienced two UTIs since being at the facility and reported staff checked and emptied her Foley bag and tubing about five times per day. A CNA observed in the room did not adjust the Foley placement to remove the urine buildup. Staff interviews stated that Foley bags should be kept off the floor and tubing should drain properly, and that failure to do so could lead to infection or obstruction. The DON stated that a Foley bag on the floor was an infection control issue and that urine pooling in the tubing was not acceptable because it could cause obstruction and infection.
Unlabeled Enteral Feeding
Penalty
Summary
The facility failed to ensure that an enteral feeding for Resident #4 was labeled in accordance with accepted professional principles. Resident #4 was a female with a history of CVA, dysphagia, and Type II Diabetes Mellitus, was NPO, and received nutrition through a gastric tube. Her care plan and physician order directed Jevity 1.2 to be administered via gastric tube at 70 ml/hour for 22 hours. During an observation on 02/15/2026 at 9:30 AM, the resident was resting in bed with enteral feeding infusing via a feeding pump at bedside, and the feeding bag had no date or name label observed. During interviews, RN I stated nurses were responsible for administering enteral feedings and were trained to label each feeding with initials and the date, and that unlabeled feedings should be disposed of. The ADON stated enteral feedings were only good for 24 hours and that the nurse who administered the feeding was responsible, typically the night shift nurse. The DON stated nurses were expected to label enteral feedings with the date so staff would know when they expired and when a new feeding was needed, and that the nurse starting the feeding was responsible for labeling it. The facility policy titled Gastronomy Tubes did not specify labeling or dating the enteral feeding.
Inaccurate wound care documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident whose wound care was reviewed. The resident had a history of chronic kidney disease, type II diabetes mellitus, and wounds on both legs. Her care plan included a left lower leg venous ulcer with interventions for staff to provide wound care as ordered and use aseptic technique. The wound care orders changed during the stay, including daily treatment to cleanse the left lower lateral distal leg wound and apply prescribed dressings and compression. The treatment record showed wound care was marked as completed on 01/31/2026 between 6 AM and 10 PM. However, during interviews, the resident’s family member stated she was with the resident on 02/01/2026, observed redness and brown drainage on the resident’s left foot and socks, and reported that the resident told her wound care had not been completed on 01/31/2026. The family member stated she notified the RN, the Wound Care Nurse, and the DON. The RN later stated he was supposed to provide the wound care that day but did not do so because he did not have normal saline and was tired at the end of his shift. He also stated he did not notify the DON or other staff that the wound care was not completed. The DON stated she reviewed the treatment record, which showed the wound care as completed, but after speaking with the resident and the RN, she learned the RN had not actually provided the treatment even though it was documented as done. The Wound Care Nurse stated weekend nurses were responsible for wound care and that supplies were available in the treatment cart and supply room. The facility policy required complete and accurate documentation for each resident on all appropriate clinical records.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 332 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 20 | 0 |
| Oasis Nursing & Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Pebble Creek Nursing Center | 5.9 mi | ★★★★★ | 10 | 0 |
| El Paso Health & Rehabilitation Center | 6.3 mi | ★★★★★ | 11 | 0 |
| Vista Hills Health Care Center | 6.9 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.