Center at Zaragoza: Infection Control Failures - TX]
The November 2025 complaint inspection cited the facility under F0880, the infection control standard, after finding problems with how staff performed perineal care, the daily cleaning of a patient's private areas. The citation affected a small number of residents. Inspectors classified the level of harm as minimal harm or potential for actual harm.
That classification understates what perineal care failures mean in practice. The perineal region is one of the most infection-prone areas of the human body. For residents who are bedridden or incontinent, the risk compounds daily. Bacteria from the rectal area, if introduced to the urethral or vaginal area during cleaning, can cause urinary tract infections and skin infections. Done correctly, perineal care prevents that. Done wrong, it causes it.
The facility's own written procedure spelled out exactly what staff were supposed to do. Introduce yourself to the patient. Explain what you are about to do. Gather supplies. Provide privacy. Wash hands. Apply gloves. Ask the patient to lie on their back. Cleanse the perineum using front-to-back motions only, with a fresh cloth or wipe for each pass. Change gloves between cares and as needed. Dispose of soiled gloves. Wash hands again.
Step seven of that procedure put the core risk in plain language: "Never wash back to front as this causes contamination and can cause infection."
The facility had written that warning into its own protocol. Inspectors found it was not being followed.
The staff responsible for this care included licensed nurses and certified nursing assistants. These are not new concepts in either profession. Front-to-back cleaning during perineal care is among the most fundamental skills taught in CNA training programs. It is not an advanced technique. It does not require specialized equipment. It requires attention and correct motion.
For residents who are bedridden, there is no self-correction available. They cannot clean themselves after a staff member finishes. They cannot tell whether the procedure was done correctly. They are entirely dependent on the person standing over them doing it right. When that person does not, the resident absorbs the consequence.
The inspection was triggered by a complaint, meaning someone, whether a resident, a family member, or another party, contacted regulators before inspectors arrived. The report does not identify who filed the complaint or what specifically prompted it. What inspectors documented when they got there was a gap between what the facility's own written procedure required and what was actually happening on the floor.
Center at Zaragoza serves residents who, by the nature of the conditions that brought them there, are already medically vulnerable. Incontinence and limited mobility are not minor inconveniences in a nursing home setting. They are daily realities that create ongoing exposure to infection if hygiene care is not performed correctly and consistently. A urinary tract infection in an elderly person can escalate quickly, leading to sepsis, hospitalization, and worse.
The citation does not indicate how long the improper technique had been in use, how many residents were affected beyond the few identified in the report, or whether any resident developed an infection as a result. Those details are not in the inspection record.
What is in the record is this: the facility had a written procedure that correctly described how to protect residents from infection during perineal care. Staff were not following it. Inspectors came in on a complaint and found the gap.
The residents at the center of this citation could not have filed that complaint themselves. They were bedridden. They needed help with the most basic functions of bodily care. Whether anyone was watching out for them before the complaint was filed, and whether the person who eventually made that call did so in time, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Center At Zaragoza, LLC from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 27, 2026 · Our methodology
Center at Zaragoza, LLC in El Paso, TX was cited for violations during a health inspection on November 21, 2025.
The citation affected a small number of residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.