Inspection Reports for
Socorro Wellness & Rehabilitation
1203 HIGHWAY 60 WEST, SOCORRO, NM, 87801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
41% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 3
Date: Dec 13, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and neglect by a staff member (CNA #1) on 10/18/24, including failure to protect residents, failure to report abuse timely, and failure to provide required staff training.
Complaint Details
The complaint investigation was triggered by an incident involving CNA #1 on 10/18/24, who was intoxicated, asleep on duty, verbally abusive, and threatening to staff and residents. The facility failed to report the incident timely and failed to provide required training to the agency staff involved.
Findings
The facility failed to protect 25 residents from abuse and neglect by a staff member who was frequently absent, asleep on duty, under the influence of alcohol, and verbally abusive. The facility also failed to report the abuse allegations within two hours and failed to provide abuse, neglect, and exploitation training to agency staff prior to working with residents.
Deficiencies (3)
Failed to protect residents from abuse and neglect by a staff member who abandoned residents, wore air pods preventing hearing, fell asleep on duty, and used abusive language.
Failed to timely report allegations of abuse and neglect to the State Agency within two hours after the incident.
Failed to provide abuse, neglect, and exploitation training to agency staff prior to working with residents.
Report Facts
Residents affected: 25
Incident date: Oct 18, 2024
Incident report submission date: Oct 25, 2024
Residents under CNA #1 care: 11
Lunch break duration: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in multiple abuse and neglect findings including intoxication, sleeping on duty, verbal abuse, and threats |
| RN #1 | Registered Nurse | Witnessed and reported CNA #1's behavior, was threatened and yelled at by CNA #1 |
| Scheduler | Responsible for CNA scheduling, notified DON and police about CNA #1's behavior | |
| DON | Director of Nursing | Interviewed regarding incident notification and facility response |
| CMA #1 | Certified Medication Aide | Reported CNA #1 sleeping on the couch and notified Scheduler |
| Nurse Aide (NA) #1 | Nurse Aide | Witnessed and recorded CNA #1's aggressive behavior |
| Human Resources (HR) | Interviewed about staff training and agency staff onboarding |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication administration, restorative services, pharmaceutical services, medication storage, food safety, and infection control at Socorro Wellness & Rehabilitation.
Findings
The facility was found deficient in developing comprehensive care plans for residents, ensuring medication administration per physician orders, providing restorative and therapy services, maintaining pharmaceutical services, properly storing medications and food, and implementing an effective infection prevention and control program including water management to prevent Legionella.
Deficiencies (10)
Failed to develop accurate, person-centered comprehensive care plans for residents #13 and #25.
Failed to revise care plan to document lost dentures for resident #30.
Failed to administer blood pressure medication per physician orders for resident #36.
Failed to maintain or improve activities of daily living for resident #12 after injury and lacked restorative nursing program.
Failed to provide restorative rehabilitation services as ordered for residents #9 and #37; facility lacked restorative program.
Failed to ensure pharmaceutical services met resident needs; resident #10 did not receive ordered turmeric supplement due to lack of supply.
Resident #25 received antipsychotic medication (Seroquel) without appropriate diagnosis; dementia not an approved indication.
Medication cart contained loose tablets not in original packaging or bubble pack.
Food safety violations including unlabeled and unsealed open food, expired seasonings, and unlabeled spices without open or use-by dates.
Failed to maintain an infection prevention and control program with an effective water management plan to minimize risk of Legionella and other waterborne pathogens.
Report Facts
Residents reviewed for care plans: 7
Residents reviewed for medication administration: 4
Residents reviewed for functional ability: 2
Residents reviewed for rehabilitation services: 2
Residents reviewed for unnecessary medications: 5
Residents affected by medication cart deficiency: 17
Residents affected by food safety deficiency: 43
Residents affected by infection control deficiency: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Confirmed care plan deficiencies, medication administration issues, pharmaceutical service gaps, and infection control program failures. |
| CMA #1 | Confirmed turmeric supplement was not available for resident #10. | |
| CMA #24 | Confirmed loose tablet found in medication cart. | |
| Lead [NAME] | Kitchen Lead | Confirmed open food not sealed or dated and expired seasonings in kitchen. |
| Maintenance Worker | Unaware of water management program or Legionella prevention. | |
| Environmental Services Director | Housekeeping and Laundry Director | Unaware of water management program or Legionella prevention. |
| CNA #17 | Certified Nursing Assistant | Reported resident #12 required full assistance and no restorative nursing was performed. |
| MDS Coordinator | Reported lack of restorative nursing program and no therapy orders for resident #12. | |
| Certified Occupational Therapy Assistant | Confirmed no therapy evaluation for resident #12 after fracture healed and no CNA instruction on ROM. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents received treatment and care in accordance with professional standards, specifically related to the continuation of antibiotic treatment for a resident's urinary tract infection.
Complaint Details
The complaint investigation found that the facility did not continue antibiotic treatment for resident R #2 after hospital discharge, despite physician orders. The Director of Nursing confirmed this during interview. Residents affected were noted as 'Some'.
Findings
The facility failed to continue administration of prescribed antibiotics for one resident (R #2) diagnosed with a urinary tract infection, resulting in potential worsening of the resident's medical condition. Documentation showed antibiotics were only administered for three days instead of the full prescribed course, confirmed by the Director of Nursing during interview.
Deficiencies (1)
Failure to continue administration of antibiotics for treatment of urinary tract infection for resident R #2.
Report Facts
Deficiencies cited: 1
Medication administration days documented: 3
Antibiotic treatment duration ordered: 10
Antibiotic treatment duration ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed resident should have continued antibiotic treatment upon hospital discharge |
Inspection Report
Routine
Census: 35
Deficiencies: 11
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Socorro Wellness & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on Saturdays, improper use of physical restraints (bed rails without orders), incomplete care plans for dental care, failure to meet professional standards for medication administration, lack of restorative therapy, inadequate activity programming in the secured memory care unit, insufficient respiratory care monitoring, lack of staff competencies, improper food labeling, and missing staff training on dementia and behavioral health care.
Deficiencies (11)
Failure to ensure residents receive mail on Saturdays.
Use of bed rails on residents without physician orders or assessments.
Failure to implement a comprehensive person-centered care plan for dental care.
Failure to meet professional standards for unnecessary medication administration including lack of parameters and missed communication with physician.
Failure to provide restorative therapy to residents needing it.
Failure to provide ongoing scheduled activities in the secured memory care unit.
Failure to monitor oxygen levels adequately for a resident on oxygen therapy.
Lack of competency evaluations for licensed nurses and CNAs.
Failure to label and date food items in the kitchen.
Failure to provide dementia care training to licensed practical nurse.
Failure to provide behavioral health training to licensed practical nurse and registered nurse.
Report Facts
Residents affected: 35
Residents affected: 2
Residents reviewed for dental care: 4
Residents reviewed for medication: 5
Oxygen saturation measurements: 29
Staff without competencies: 5
Residents reviewed for activities: 9
Staff without dementia care training: 1
Staff without behavioral health training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Named in dementia care and behavioral health training deficiencies |
| RN #12 | Registered Nurse | Named in behavioral health training deficiency and lack of competencies |
| Administrator | Interviewed regarding mail delivery, staff competencies, and training deficiencies | |
| DON | Director of Nursing | Interviewed regarding bed rail orders, restorative therapy, and staff competencies |
| Dietary Manager | Interviewed regarding food labeling deficiencies | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen monitoring practices |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, bed hold policies, care plan updates, and discharge summary documentation at Socorro Wellness & Rehabilitation.
Findings
The facility failed to provide timely written notices of transfer and bed hold policies for residents transferred to hospitals, failed to update care plans to reflect resident transfers, and did not complete discharge summaries at the time of discharge for several residents. These deficiencies could result in residents and their representatives being uninformed about their rights, care plans, and discharge information.
Deficiencies (4)
Failed to notify residents and their representatives in writing of transfers and reasons for the move for 3 residents.
Failed to provide written notice of bed hold policy at the time of transfer for 3 residents.
Failed to revise the care plan for 1 resident to reflect transfer to a different facility.
Failed to ensure discharge summaries including recapitulation were completed at time of discharge for 3 residents.
Report Facts
Residents sampled for hospitalizations: 3
Residents sampled for care plans: 6
Residents sampled for discharge: 4
Days delay in discharge summary completion: 2
Days delay in discharge summary completion: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed deficiencies related to notice of transfer, bed hold policy, care plan updates, and discharge summaries |
Inspection Report
Routine
Census: 43
Deficiencies: 17
Date: Apr 26, 2022
Visit Reason
Routine inspection of Socorro Wellness & Rehabilitation to assess compliance with healthcare regulations including resident rights, care planning, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate resident notification of rights and transfer policies, incomplete and inaccurate care plans, improper medication management, insufficient hydration, delayed meal service due to staffing shortages, improper food handling and storage, incomplete medical documentation, deficient infection prevention and control program, lack of antibiotic stewardship, and failure to provide required staff training on abuse, neglect, and exploitation.
Deficiencies (17)
Failed to provide dignity cover for Foley catheter bag for resident #37.
Failed to ensure residents knew how to contact Ombudsman and view survey results.
Failed to provide timely written notice of hospital transfers and bed hold policies for residents #21, #39, and #40.
Failed to develop and implement complete, accurate care plans for multiple residents including medication orders, chronic pain, and advanced directives.
Failed to revise care plans timely for advanced directives, falls, activities of daily living, medications, and edema for multiple residents.
Failed to properly assess and manage anxiety and side effects of psychotropic medications for residents #5 and #31.
Failed to consistently offer water to residents #8, #10, and #12, resulting in inadequate hydration.
Failed to assess and document pain levels before and after administration of scheduled pain medication for residents #11 and #26.
Failed to discontinue or reevaluate psychotropic medications given as PRN for more than 14 days for residents #7 and #21.
Failed to monitor medication and lab refrigerator temperatures and medication room temperatures daily; stored expired medications with unexpired; medication cart unsecured.
Failed to provide sufficient support personnel for food and nutrition services, causing delayed meal service.
Failed to follow proper infection control practices including glove use and hand hygiene during meal service; failed to label and date opened food in pantry.
Failed to accurately document diagnoses and medical orders including missing order for Foley catheter and incomplete MOST form.
Failed to maintain an effective infection prevention and control program including lack of national infection definitions, facility assessment use, annual review, process surveillance, staff training, and proper mask use.
Failed to implement a functional antibiotic stewardship program including monitoring antibiotic use, tracking outcomes, performing 48-hour timeouts, and providing staff education.
Failed to offer pneumococcal vaccine to residents #3 and #5 despite provider orders.
Failed to provide annual training on abuse, neglect, and exploitation for staff member RN #1.
Report Facts
Residents affected: 43
PRN Alprazolam administration days: 14
PRN Lorazepam administration days: 8
Medication refrigerator temperature missing days: 15
Medication refrigerator temperature missing days: 20
Medication room temperature missing days: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #21 | Registered Nurse | Confirmed expired medications and supplies in medication room and cart |
| DON | Director of Nursing | Confirmed multiple deficiencies including infection control program, pain assessment, hydration, and medication cart security |
| Administrator | Facility Administrator | Confirmed staffing shortages, delayed meal service, expired medications, and lack of pneumococcal vaccine offer |
| DS #21 | Dietary Staff | Observed failing to change gloves and perform hand hygiene while serving residents |
| IP/DON | Infection Preventionist/Director of Nursing | Confirmed lack of infection prevention program and antibiotic stewardship |
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