Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Cruces Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
A treatment cart containing medical supplies and equipment was found unlocked and unattended on a unit with 16 residents. Staff, including a CNA and the Wound Care Nurse, confirmed the cart was left unsecured with the keys in it, and the DON acknowledged that the cart should be locked when staff are not present.
A resident admitted with a surgical wound and IV access, both requiring enhanced barrier precautions (EBP) per physician's orders, did not have EBP documented in the baseline care plan. The DON confirmed the omission and acknowledged that EBP should have been included in the care planning process.
Two residents who required enhanced barrier precautions for wounds and IV access did not have these interventions documented in their care plans, despite physician orders. The DON confirmed that the care plans were incomplete and should have included the necessary infection control measures.
A resident with significant fall risk factors, including cognitive impairment and mobility limitations, was left unsupervised in the restroom by a CNA who did not review the care plan or use the Kardex. The resident subsequently fell, as staff failed to implement required interventions outlined in the care plan.
A resident with severe cognitive impairment, mobility issues, and a high risk for falls was left alone in the bathroom by a CNA, who went to assist another resident. The CNA did not review the care plan and relied on shift reports, resulting in the resident being found on the floor after being left unattended. The DON confirmed that the resident should not have been left alone and that staff are expected to follow care plans.
A resident with multiple health conditions experienced a fall, but the SBAR form was left incomplete and the incident was not documented in the progress notes by the LPN on duty. The DON confirmed that required documentation was missing after the fall.
A resident with a UTI missed 10 doses of the prescribed antibiotic cefuroxime due to the facility not receiving it from the pharmacy. The MAR showed the missed doses, and there was no documentation of provider notification. The DON confirmed the oversight during an interview.
The facility did not report investigation results of suspected abuse incidents involving two residents to the State Agency within the required timeframe. One resident suffered a hip displacement requiring surgery, while another had a fall without serious injury. The Administrator could not confirm or provide proof of report submission, and the State Agency had no record of receiving the reports.
The facility failed to properly notify residents and their representatives about hospital transfers, lacking documentation and omitting required contact information for the State Long-Term Care Ombudsman. Interviews revealed that while families were notified by phone, written notices were not provided, and incorrect Ombudsman contact details were used.
The facility failed to notify residents and their representatives in writing about the bed hold policy during hospital transfers. Medical records for four residents lacked documentation on the duration of the bed hold and notification details. Interviews revealed confusion among staff regarding responsibility for bed hold notifications, with the Business Office not handling the forms as expected.
The facility failed to ensure complete care plans for three residents, leading to potential unawareness of their needs by the staff. One resident's care plan did not address the discharge plan, another's lacked documentation of a Midline catheter and care instructions, and a third's was missing interventions for cellulitis, wound care, and PICC line management. These omissions could result in inadequate care for the residents' medical conditions.
The facility failed to update care plans with current information and ensure IDT participation in meetings. A resident's fluid restriction was not documented, leading to non-compliance, and another resident's PEG tube care was inadequately specified. Additionally, a resident's care plan was not updated after ingesting cream, despite behavioral issues. The DON confirmed these oversights.
A resident with a UTI did not receive 10 out of 13 doses of the prescribed antibiotic cefuroxime due to the facility's failure to obtain the medication from the pharmacy. Despite being on order, the medication was not available in the emergency kit, medication cart, or pyxis, as confirmed by the DON. This resulted in the resident not receiving appropriate treatment for the UTI.
A facility failed to ensure timely documentation of a resident's care by the provider. The resident's medical record showed multiple late entries for progress notes, all entered on the same day, long after the visits occurred. The nurse practitioner admitted to being behind on documentation and waiting to enter notes collectively. The administrator expected timely entries but did not define 'timely'.
A facility failed to ensure a resident had a physician visit every 30 days for the first 90 days after admission. The resident's EMR lacked documentation of any physician visits, and the Administrator confirmed the absence of such records. The Administrator was also unsure of the physician's visit frequency, despite expecting visits every 30 days.
The facility failed to properly store medications for 17 residents in specific rooms, as a loose white tablet was found in the medication cart. An LPN confirmed the presence of the loose tablet and intended to remove it. The facility's policy requires proper storage to maintain medication integrity and ensure safe administration.
A resident with dysphagia required post-meal checks for pocketed food, but the facility failed to document these checks. An LPN admitted to not documenting the checks and was unsure if they were being performed. The DON confirmed the lack of documentation, despite expectations for staff to record these checks.
The facility did not create baseline care plans within 48 hours for four residents, omitting critical physician's orders and diagnoses such as antibiotics for UTIs, continuous oxygen use, rheumatoid arthritis and diabetes medications, and dementia with antipsychotic treatment. These omissions were confirmed by the DON and Social Services.
A facility failed to complete a comprehensive MDS assessment within the required 14-day period for a resident. The resident was admitted, but the MDS assessment was only completed after the deadline. The MDS Nurse confirmed the delay and acknowledged the expectation for timely completion, which could lead to unmet care needs.
A resident with behavior problems and impulsivity ingested skin cream due to the facility's failure to store creams out of reach. The resident had a history of unsafe behaviors, yet was not assessed for potential danger, leading to the incident.
A facility failed to follow proper infection control practices when a resident's nasal cannula tubing was not labeled with the date it was changed. The resident had specific physician's orders for oxygen delivery, and an LPN confirmed the oversight, citing the busy work environment as a reason for forgetting to date the tubing.
The facility failed to maintain a homelike environment for 46 residents due to several burnt-out and flickering light bulbs in the dining room. An observation revealed multiple lighting issues, and the Administrator confirmed the problem, stating that an order for replacement was in place without a specified date.
The facility failed to revise the care plan for a resident with a Stage III pressure ulcer who frequently refused repositioning and offloading. Despite staff being aware of the resident's noncompliance, this information was not documented in the care plan, leading to potential gaps in care.
Unsecured Treatment Cart Left Unattended
Penalty
Summary
A deficiency was identified when staff failed to secure a treatment cart containing medical supplies and equipment on the South Unit, where 16 residents reside. On the morning of 11/26/25, an observation revealed the treatment cart was left unlocked with the keys in it, and no staff were present in the area. This was confirmed by a CNA and the Wound Care Nurse during interviews, both acknowledging the cart was unsecured. The Director of Nursing also confirmed that the treatment cart should be locked if staff are not present.
Failure to Document Enhanced Barrier Precautions in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan for one of three residents sampled for enhanced barrier precautions (EBP), an infection control intervention aimed at reducing the transmission of multidrug-resistant organisms (MDROs). Record review showed that the resident was admitted with a surgical wound to the right hip and required IV access, both of which necessitated EBP as per physician's orders. However, the baseline care plan did not document the need for EBP for the surgical wound and IV access. During an interview, the Director of Nursing confirmed that the resident's baseline care plan was missing the required EBP documentation and acknowledged that the facility team should have included this information.
Failure to Include Enhanced Barrier Precautions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two of three residents sampled who were on enhanced barrier precautions (EBP) for infection control related to wounds and IV access. For one resident, physician's orders indicated the need for EBP due to a wound on the left leg and IV therapy, but the care plan did not document these precautions. Similarly, another resident had physician's orders for EBP for a wound on the right foot and IV access, yet the care plan lacked this information. The Director of Nursing confirmed during interviews that the care plans for both residents did not include the required EBP interventions and acknowledged that the facility team should have included these precautions in the care planning process.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident with multiple risk factors for falls, including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and a need for assistance with personal care. The care plan identified the resident as being at risk for falls due to gait, balance, and cognitive deficits, and required staff to review past falls, determine causes, and implement interventions. Despite these documented needs and interventions, a certified nursing assistant (CNA) left the resident alone in the restroom after assisting them, instructing the resident to use the call light when finished. The CNA left to assist another resident and returned after 5-6 minutes to find the resident on the floor, indicating the resident had fallen while unsupervised. The CNA reported not reviewing the resident's care plan and relying solely on shift reports for instructions, and also stated not having access to the Kardex, which contains important patient information. The Director of Nursing (DON) confirmed that the resident should not have been left alone on the toilet and that staff have access to the care plan, which is also available in the Kardex. The failure to follow the care plan and ensure staff were aware of and implemented required interventions directly led to the resident being left unsupervised and experiencing a fall.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A cognitively impaired resident with multiple diagnoses, including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and a need for assistance with personal care, was left unattended in the bathroom by a CNA. The resident required substantial to maximal assistance for toileting hygiene, toilet transfers, and sit-to-stand movements, as documented in the care plan and MDS assessment. The care plan specifically identified the resident as being at risk for falls due to gait, balance, and cognitive deficits, and required interventions to address these risks. Despite these documented needs, the CNA left the resident alone in the restroom to assist another resident, instructing the resident to use the call light when finished. Upon returning after 5-6 minutes, the CNA found the resident on the floor. The CNA admitted to not reviewing the care plan and not having access to the Kardex, relying instead on shift reports. The DON confirmed that the resident had a severely impaired BIMS score and that the CNA should not have left the resident unattended, as staff are expected to follow care plans, which are accessible through the Kardex.
Incomplete Medical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident. Specifically, the resident, who had multiple diagnoses including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and required assistance with personal care, experienced a fall. The Situation-Background-Assessment-Recommendation (SBAR) form related to the fall was not signed or completed, and there was no documentation of the fall in the resident's progress notes by the LPN who was on duty at the time. The Director of Nursing confirmed that staff did not complete the SBAR note or document a progress note after the fall.
Failure to Notify Provider of Missed Antibiotic Doses
Penalty
Summary
The facility failed to notify the provider of missed medication doses for a resident diagnosed with a urinary tract infection (UTI). The resident was prescribed cefuroxime, an antibiotic, to be taken twice daily for 10 days. However, the medication administration record (MAR) indicated that the resident missed 10 doses over several days. The nurse progress notes did not document any notification to the provider about these missed doses. During an interview, the Director of Nursing (DON) confirmed that the doses were missed because the facility did not receive the medication from the pharmacy and could not confirm that the provider was notified.
Failure to Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of investigations into suspected abuse incidents involving two residents to the State Agency within the required five-day period. Resident #270 experienced a fall that resulted in an emergency room visit and a diagnosis of acute displacement of the left hip, necessitating surgery. Despite this serious incident, there was no documentation indicating that a follow-up report was submitted to the State Agency. Similarly, Resident #271 sustained a fall that led to an ER visit, although no serious injury was reported. Again, there was no documentation of a follow-up report being sent to the State Agency. During an interview, the Administrator was unable to confirm or provide proof of when these reports were sent, and a review of the State Agency Reporting system showed no record of receiving the reports for either resident.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely and proper notification to residents and their representatives regarding transfers to the hospital. Specifically, for four residents, the facility did not document that a copy of the transfer notice was provided to the resident representatives. Additionally, the transfer notices lacked the name, phone number, and address of the Office of the State Long-Term Care Ombudsman. Furthermore, the facility did not send a written copy of the transfer notices to the Ombudsman for three of the residents. These deficiencies were confirmed through record reviews and interviews with facility staff, including the Administrator, Social Worker, and LPN. The report highlights specific instances where the facility's staff did not adhere to the required procedures for notifying residents and their representatives about hospital transfers. For example, one resident was transferred to the hospital without a documented transfer notice, and the Administrator confirmed the absence of such documentation. Interviews with the Social Worker and LPN revealed that while they notify families by phone, they do not provide written transfer notices to the families or the Ombudsman. Additionally, the binder at the nurse's station contained incorrect contact information for the Ombudsman, listing a Volunteer Ombudsman instead of the official contact details.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and their representatives during hospital transfers, affecting four residents. The medical records of these residents lacked documentation on the duration of the bed hold, who was notified, and whether the notification was provided to the residents or their families. This deficiency was identified through record reviews and interviews, revealing that the facility did not ensure proper communication regarding bed hold policies. Interviews with staff, including an LPN and the Business Office Manager, highlighted a lack of clarity and responsibility in handling bed hold notifications. The LPN indicated that nurses create the bed hold notice document but do not complete it, leaving it to the Business Office, which in turn does not handle the forms. The Administrator confirmed the absence of documentation for one resident's transfer, acknowledging the expectation for bed hold notifications to be signed by residents or their representatives promptly.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to ensure complete care plans for three residents, leading to potential unawareness of their needs by the staff. For Resident #106, the care plan did not address the discharge plan or any referrals to the local contact agency, as confirmed by Social Services. Resident #108's care plan lacked documentation of a Midline catheter and instructions for its care, despite physician's orders for its maintenance. The MDS Nurse confirmed these omissions, highlighting the need for resident-specific care plans. Resident #265's care plan was incomplete, missing documentation of interventions for cellulitis, two wounds on the right leg, and the presence of a PICC line. The MDS Nurse confirmed these deficiencies, noting that the care plan only included medication orders for pain and lacked specific instructions for observing and managing cellulitis. These omissions could result in inadequate care for the residents' medical conditions.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to revise care plans with the most current resident information and did not ensure the participation of the required Interdisciplinary Team (IDT) members in care plan meetings for several residents. For one resident, there was no documentation of a care plan meeting, and the social services staff confirmed that no meeting had occurred. Another resident's family member was not invited to care plan meetings and was unaware of their ability to attend, with the care plan not being completed with IDT members due to the facility's short-term nature. In another case, a resident receiving dialysis had a fluid restriction order that was not documented in the care plan. The resident exceeded fluid intake limits multiple times, and the Certified Nursing Assistants (CNAs) were not informed of the fluid restrictions, leading to a lack of adherence to the prescribed care. The Director of Nursing (DON) confirmed that the fluid restriction was not care planned, acknowledging it was overlooked. Additionally, a resident with a PEG tube had a care plan that did not specify the required care for the tube, despite having physician orders for its maintenance. Another resident with behavioral issues ingested cream, but the care plan was not updated to reflect this incident or the necessary interventions to prevent recurrence. The DON confirmed the care plan should have been revised to include these details.
Failure to Administer Prescribed Antibiotic for UTI
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of urinary tract infection (UTI) received appropriate treatment. The resident, who was discharged to the facility from the hospital with a UTI, was prescribed cefuroxime, an antibiotic, to be taken twice daily for 10 days. However, the medication administration record (MAR) indicated that the resident missed 10 out of 13 doses of the prescribed antibiotic over several days. The deficiency occurred because the facility did not receive the medication from the pharmacy, as confirmed by the Director of Nursing (DON). Progress notes repeatedly documented that the cefuroxime was on order but not available in the emergency kit, medication cart, or pyxis. This lack of medication availability led to the resident not receiving the necessary treatment for the UTI, potentially putting the resident at risk for worsening infection.
Failure to Timely Document Provider Progress Notes
Penalty
Summary
The facility failed to ensure that a resident's care was reviewed and documented by the provider at each required visit. Specifically, the facility did not have written, signed, and dated progress notes from the provider for a resident at the time of each visit. The resident's electronic medical record showed multiple instances where progress notes were entered as late entries, all on the same date, well after the actual visits occurred. These late entries spanned several dates over a period of months, indicating a significant delay in documentation. Interviews with the nurse practitioner revealed that he was behind on entering progress notes into the medical records and had entered several late entries for the resident on a single day. He admitted to waiting to collect a series of notes before entering them into the system. The facility administrator confirmed that her expectation was for providers to enter their notes in a timely manner, although she did not specify what constituted 'timely'. This lack of timely documentation could result in the resident's needs not being met due to facility staff being unaware of the resident's current status.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident had a physician visit at least every 30 days for the first 90 days after admission. A review of the electronic medical record (EMR) for the resident revealed no documentation indicating that the resident was seen by a physician. During an interview, the Administrator confirmed the absence of physician documentation in the resident's medical record and was unable to determine if the resident had been seen by a physician. Additionally, the Administrator was unsure of the frequency with which the resident's physician visits the facility, although her expectation was for physicians to see their residents at least once every 30 days for the first 90 days.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to properly store medications for all 17 residents in rooms 135-151, as identified by the Resident Matrix. During an observation of the medication cart assigned to these rooms, a loose white oval tablet was found between the medication cards in the second drawer of the cart. This was confirmed by an LPN, who acknowledged the presence of the loose tablet and stated they would remove it. The facility's Storage of Medication Policy, dated September 2018, requires that medications and biologicals be stored properly to maintain their integrity and support safe, effective drug administration. The policy also specifies that medication storage should be clean, well-lit, organized, and free of clutter.
Incomplete Documentation of Dysphagia Care
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one of the residents reviewed for documentation accuracy. The resident in question had a diagnosis of dysphagia, which required their mouth to be checked for pocketed food and debris after meals. However, it was found that the nurses, who were responsible for performing these checks, did not document when they checked the resident for pocketing after meals. During interviews, an LPN admitted to not documenting these checks and expressed uncertainty about how to verify if the checks were being performed. The Director of Nursing confirmed that staff did not document these checks, despite the expectation that they should be doing so.
Failure to Create Timely Baseline Care Plans
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for four residents, which accurately reflected their current medical conditions and physician's orders. For one resident, the baseline care plan did not include the physician's orders for an antibiotic and continuous use of oxygen, despite the resident having a diagnosis of a urinary tract infection and requiring oxygen therapy. Another resident's care plan was incomplete and lacked the physician's orders for an antibiotic treatment for a urinary tract infection. Additionally, the baseline care plan for a third resident did not document the physician's orders for medications used to treat rheumatoid arthritis and diabetes. A fourth resident's care plan was not completed within the required timeframe and failed to include the diagnosis of dementia and the physician's orders for an antipsychotic medication. These deficiencies were confirmed through interviews with the Director of Nursing and Social Services, indicating a lack of proper documentation and planning for the residents' immediate healthcare needs upon admission.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the federally mandated 14-day period following a resident's admission. Specifically, the deficiency involved one resident, identified as R #266, whose admission MDS assessment was not completed within the required timeframe. The resident was admitted on an unspecified date, and the MDS assessment was only completed on July 1, 2024, exceeding the 14-day requirement. During an interview, the MDS Nurse confirmed that the assessment was not completed on time and acknowledged the expectation for such assessments to be completed within 14 days of admission. This oversight could potentially result in the resident's preferences and care needs not being adequately addressed.
Failure to Secure Skin Creams Leads to Resident Ingestion
Penalty
Summary
The facility failed to ensure that skin creams were stored out of reach of a resident, leading to an incident where the resident ingested a cream. The resident, who had a history of behavior problems and impulsivity, was found with white cream on her teeth and tongue, prompting a hospital visit. Upon investigation, it was discovered that two tubes of barrier cream and an empty jar of zinc cream were in the resident's bedside drawer, indicating that the creams were accessible to her. The resident's care plan noted her impulsivity and poor safety awareness, yet she was not assessed for potential danger despite previous incidents of removing her midline catheter and tampering with electrical outlets. The Director of Nursing confirmed that the resident's impulsivity and lack of safety awareness should have prompted an assessment for potential danger, which was not conducted. This oversight contributed to the resident's access to and ingestion of the creams.
Infection Control Deficiency: Undated Nasal Cannula Tubing
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident identified during a random observation. Specifically, the nasal cannula tubing used for delivering oxygen to the resident was not labeled with the date it was changed. This oversight was observed during a room inspection, where it was noted that the tubing lacked a date to indicate when it had been replaced. The resident had physician's orders for oxygen titration and a specific oxygen flow rate via nasal cannula. During an interview, an LPN confirmed that the nasal cannula tubing was not dated and mentioned that the tubing is typically changed on Sundays. However, due to the busy nature of their work, staff sometimes forget to check if the tubing is dated, leading to this deficiency.
Failure to Maintain Homelike Environment Due to Lighting Issues
Penalty
Summary
The facility failed to provide a homelike environment for all 46 residents, as evidenced by the condition of the dining room lighting. During an observation on June 25, 2024, it was noted that several light bulbs in the dining room were either burnt out or flickering. Specifically, the first ceiling circular hanging light had three bulbs burnt out and one flickering, the second ceiling circular light had four bulbs burnt out, the bistro light near the hallway had one bulb burnt out, and the middle circular hanging light had one bulb burnt out. An interview with the Administrator on June 27, 2024, confirmed the issue, and she stated that there was an order for the bulbs to be replaced, although no specific date was provided for this action.
Failure to Revise Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident (R #11) who had a Stage III pressure ulcer upon admission. Despite the resident's frequent refusals to be repositioned and noncompliance with offloading, these refusals were not documented in the care plan. Interviews with the Wound Care Nurse and a CNA confirmed that the resident often refused repositioning and preferred to remain on her back, but this information was not included in the care plan. Additionally, the care plan did not provide guidance on what staff should do when the resident refused offloading and repositioning. The Director of Nursing confirmed that the resident's refusals and noncompliance were not care planned, acknowledging that these should have been documented. This oversight could lead to staff being unaware of the resident's care preferences and needs, potentially impacting the quality of care provided.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — 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 Las Cruces
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calibre Post Acute, Llc | 0.6 mi | ★★★★★ | 11 | 0 |
| Casa Del Sol Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Northrise Wellness & Rehabilitation | 2.2 mi | ★★★★★ | 7 | 0 |
| Las Cruces Village Nursing & Rehabilitation Llc | 2.3 mi | ★★★★★ | 14 | 0 |
| Casa De Oro Center | 9.7 mi | ★★★★★ | 21 | 0 |
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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.