Socorro Wellness & Rehabilitation

Inspectors wroteBased on record review, and interviews, the facility failed to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This has the potential to affect all 54 residents in the facility (residents were identified by the resident matrix provided by the DON on 07/09/26). If the facility does not maintain grievance evidence, then residents' concerns could go without resolution leaving residents feeling frustration and helpless.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain sufficient nursing staffing to ensure the highest practicable physical, mental, and psychosocial well-being of each resident. This failure has the potential to affect all 54 residents (residents were identified by the resident census list provided by the DON on 07/09/26). This deficient practice could likely result in residents not receiving the care and service needed while in the facility.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications, which could affect all 59 residents in the facility (Residents were identified by the resident matrix provided by the ADON on 12/09/25), when they failed to: 1. Ensure medications were not expired in the medication room. 2. Ensure medications were not expired in the electronic medication management dispensing machine. This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for Quarter #4 (July 1, 2024-September 30, 2024). This has the potential to affect all 59 residents in the facility, (residents were identified by the Resident Matrix provided by the ADON on (12/08/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless there was adequate monitoring for any adverse consequences resulting from the medication for 1 (R #8) of 5 (R #3, R #8, R #25, R #36, and R #70) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure psychotropic medications were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representatives in writing for 3 (R #2, R #5, and R #66) of 3 (R #2, R #5, and R #66) residents sampled for hospitalizations, when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R # 2 and R #5. 2. Ensure residents or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held for R #66. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 4 (R #2, R #25, R #69, and R #70) of 5 (R #2, R #7, R #25, R #69, and R #70) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review observation, and interview, the facility failed to ensure care plan revisions occurred for 6 (R #7 R #8, R #17, R #25, R #36, and R #60) of 8 (R #5, R #6, R #7, R #8, R #17, R #25, R #36, and R #60) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #6) of 2 (R #5 and R #6) residents when staff failed to: 1. Identify open wounds on R #6's lower legs. 2. Follow up on the burning sensation when R #6 urinated. These deficient practices could likely lead to residents needs not being met and/or a worsening of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for oxygen therapy for 3 (R #7, R #69, and R #76) of 3 (R #7, R #69, and R #76) residents reviewed for respiratory care, when staff failed to: 1. Ensure residents wore their oxygen continuously for R #7 and R #76. 2. Ensure oxygen concentration was administered per physician's order for R #69. 3. Document respiratory assessments (a systematic evaluation of breathing, using inspection, palpation, percussion, and auscultation to check vital signs, observe breathing patterns, feel the chest, tap for sounds, and listen with a stethoscope for lung sounds and chest movement) for R #69. [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure residents obtained dental services for 4 (R #6, R #7, R #36, and R #60) of 8 (R #4, R #5, R #6, R #7, R #10, R #17, R #36, and R #60) residents sampled for dental services, when staff failed to: 1. Schedule a follow up visit for R #6. 2. Schedule routine annual dental services for R #7 and R #60. 3. Schedule dental services for R #7's broken tooth. 4. Schedule dental services after R #36 lost her dentures. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. R #6 A. Record review of R #6's admission record, no date, revealed R #6 was admitted to the facility on [DATE]. B. On 12/10/25 at 10:05 AM, during an interview, R #6 stated that he has problems with his teeth. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #7, R #69, and R #76) of 3 (R #7, R #69, and R 76) residents reviewed for respiratory treatment when staff failed to: 1. Document oxygen concentrator (a medical device that provides concentrated oxygen to people with breathing problems by taking in ambient air, removing nitrogen and impurities, and delivering purified, oxygen-enriched air through a nasal cannula or mask) rates for residents requiring oxygen for R #7, R #69, and R #76. 2. Ensure resident's orders entered in the computer matched the admitting orders for R #69 and R #76. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) to the State Agency within 24 hours of allegation for 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of funds, when staff failed to report allegations of missing money. If the facility fails to report allegations of misappropriation of resident funds to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their money is not being protected.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of resident funds when staff failed to have evidence of a thorough investigation of misappropriation of resident funds. If the facility does not adequately investigate allegations of misappropriation of resident funds, then corrective action is not implemented to protect other residents from misappropriation of resident funds, then residents may suffer increased anxiety and fear that their money is not being protected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #36) of 8 (R #4, R #5, R #6, R #7, R #10, R #17, R #36, and R #60) residents reviewed for dental care. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #5 and R #17) of 7 (R #5, R #6, R #7, R #17, R #36, R #69 and R #76) residents reviewed for neglect when staff failed to follow physician orders. If the facility is not providing care per physician's orders, and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure appropriate treatment for urinary conditions (conditions affect the kidneys, bladder, and tubes connecting them, ranging from common issues like Urinary Tract Infections (UTIs), incontinence, and kidney stones to more complex problems like overactive bladder, interstitial cystitis, and prostate issues (in men) for 1 (R #2) of 4 (R #2, R #5, R #6, and R #76) resident's reviewed for urinary conditions, when staff failed to provide services for Foley Catheter tubing (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for R #2. This deficient practice could result in residents being susceptible to worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues)

Inspectors wroteBased on record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #8 and R 69) of 2 (R #8 and R #69) residents reviewed for hospice services when staff failed to: 1. Ensure resident medical records had relevant communication indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for R #8 and R #69. 2. Ensure there was a coordinated plan of care in R #8's medical record delineating services that hospice was responsible for and services the facility was responsible for. These deficient practices could likely lead to residents not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the bed rail and bed were compatible for 1 (R #17) of 1 (R #17) resident reviewed for accidents. This deficient practice could likely result in serious injury if residents fall while attempting to transfer while using the bed rail.

Inspectors wroteBased on record review and interview, the facility failed to protect 25 out of 25 residents on the secure unit and North Hall (residents were identified by the resident census report, dated 10/18/24, provided by the Administrator on 12/13/24) sampled for abuse and neglect, when a staff member: 1. Abandoned residents by frequently leaving the building to go to his car multiple times throughout the shift. 2. Wore air pods (wireless headphones for listening to music and answering phone calls) in both ears, which prevented him from hearing what was occurring on the unit. 3. Fell asleep on the unit couch during the dinner meal. 4. Used loud, foul, abusive language. These deficient practices could result in residents' needs not being met, staff not being unaware of urgent resident needs, and residents feeling unsafe in their home.

Inspectors wroteBased on record review and interview the facility failed to report alleged allegations of abuse and neglect to the State Agency for 25 out of 25 residents on the secure unit and north hall (residents were identified by the resident census report, dated 10/18/24, provided by the Administrator on 12/13/24) sampled for abuse and neglect, when they failed to report allegations of abuse and neglect by CNA #1 on 10/18/24 within two hours after the incident. If the facility fails to report allegations of abuse and neglect timely, then corrective action may not be taken, and residents could likely suffer serious bodily injury or a decline in their psychological well-being. A. Record review of the Incident Report, dated 10/25/24, revealed the following: 1. An abuse and neglect type of incident occurred on 10/19/24 at 6:00 PM. 2. CNA #1 was asleep on the job. 3. CNA #1 smelled of alcohol. 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide abuse, neglect, and exploitation (ANE) training to 1 (CNA #1) of 3 (CNA #1, CNA #2, and CNA #4) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation.

Inspectors wroteBased on observation and interview, the facility failed to store food and spices in accordance with professional standards of food service safety for all 43 residents (residents were identified on the resident census provided by the Administrator on 08/26/24) who ate food prepared in the kitchen when they failed to: 1. Label open food in the refrigerator. 2. Properly seal open food in the refrigerator. 3. Ensure spices were labeled with open dates. 4. Remove expired seasoning. These deficient practices could likely lead to foodborne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia] and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 43 residents who lived in the facility (residents were identified by the Resident Matrix provided by the DON on 08/26/24). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #10) of 4 (R #10, R #22, R #29, and R #36) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved medical issues.

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #13 and R #25) of 7 (R #10, R #12, R #13, R #23, R #25, R #29 and R #32) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan revision occurred for 1 (R #30) of 4 (R #5, R #7, R #11, and R #30) residents reviewed for care plans, when they failed to update R #30's care plan to document that her lower dentures were lost. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #36) of 4 (R #10, R #22, R #29, and R #36) residents reviewed for medication administration, when staff did not administer R #36's blood pressure medication regardless of specific parameters (numerical or another measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADLs) was maintained or improved for 1 (R #12) of 2 (R #12 and R #25) residents reviewed for functional ability (the actual or potential capacity of an individual activity and tasks that can be normally expected). If the facility does not ensure that residents maintain or improve their functional abilities, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury) services as ordered by the physician for 2 (R #9 and #37) of 2 (R #9 and #37) residents reviewed for rehabilitation services. This deficient practice is likely to result in a decrease in residents functional mobility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis for 1 (R #25) of 5 (R #5, R #11, R #12, R #13, and R #25) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on observation, and interview, the facility failed to store medications properly for all 17 residents in the East Unit (residents were identified by the Resident Matrix provided by the Administrator on 08/26/24), when they failed to ensure the medication cart did not contain loose medications. This deficient practice could likely result in residents obtaining or being administered medication not prescribed to them, receiving medications that are less effective, and may result in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for hospitalizations, when they failed to continue the administration of antibiotics for treatment of urinary tract infection (UTI; infection of the urinary system). This deficient practice could likely lead to residents needs not being met and/or a worsening of their medical condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents receive mail on Saturday's for all 35 residents identified on the census provided on 07/10/23 by the Administrator. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This could affect all 35 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on 07/10/23). This deficient practice could likely result in Nurses and CNA's working with residents without adequate competencies to do; likely resulting in injury or inappropriate care being provided to the residents.

Inspectors wroteBased on observation and interview, the facility failed to label food in accordance with professional standards of food service safety. This could affect all 35 residents in the facility who eat food prepared in the kitchen (residents were identified Resident Matrix provided by the Administrator on 07/10/23), when they failed to ensure food items in the kitchen labeled and dated. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 2 (R #27 and R #33) of 3 (R #25, R #27, and R #33) residents randomly sampled, when staff used the bed rails on R #27 and R #33's bed. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 1 (R #12) of 5 (R #12, R #25, R #27, R #29 and R #35) residents reviewed for unnecessary medications when they failed to: 1. Have parameters (numerical values) in place to determine when to administer or when to hold (not provide) blood pressure medication 2. Consistently measure blood pressure to determine effectiveness of medication or changes in blood pressure due to missed doses of medication 3. Report to physician when missed medication several days in a row These deficient practices could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the therapeutic (desired) effect of the medication due to it not being administered.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #29) of 2 (R #12 and R #29) residents are receiving restorative therapy (a therapy in which a patient trains on abilities they already have to perfect them). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, sit, stand, and perform other ADL's (Activities of Daily Living).

Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing activity program for 9 (R #9, R #14, R #16, R #22, R #23, R #24, R #25, R #33 and R #191) of 9 (R #9, R #14, R #16, R #22, R #23, R #24, R #25, R #33 and R #191) residents reviewed for activities in the secured memory care unit. This deficient practice could likely cause boredom, isolation, anxiousness, and feeling helpless.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care (breathing support) consistent with professional standards for 1 (R #12) of 2 (R #12 and R #13) residents reviewed for respiratory care when the facility failed to monitor R #12's oxygen levels. If the facility fails to monitor the resident's oxygen levels, they may fail to provide the resident with supplemental oxygen (additional oxygen to maintain oxygen levels above 90%) as needed.

Inspectors wroteBased on record review and interview, the facility failed to provide Dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells) Care training, to 1 (LPN #11) of 3 (LPN #11, RN #11, and RN #12) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being.

Inspectors wroteBased on record review and interview, the facility failed to provide Behavioral Health (the emotions and behaviors that affect your overall well-being) training, to 2 (LPN #11 and RN #12) of 3 (LPN #11, RN #11, and RN #12) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being.

Inspectors wroteBased on record review, observation, and interview, the facility failed to implement a comprehensive person-centered care plan for 1 (R #13) of 4 (R #7, R #13, R #19, and R #33) residents reviewed for dental care. Failure to implement a resident-centered care plan may result in staff's failure to understand and implement the needs of residents, likely resulting in residents not receiving the care and/or treatment needed.