Inspection Reports for Las Cruces Wellness & Rehabilitation LLC
175 N ROADRUNNER PARKWAY, NM, 88011
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
16 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 16
Deficiencies: 3
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning, infection control, and safety standards in the nursing home, focusing on residents under enhanced barrier precautions and safety hazards related to treatment cart security.
Findings
The facility failed to develop complete baseline and comprehensive care plans for residents on enhanced barrier precautions, potentially leading to staff unawareness of resident needs. Additionally, the facility failed to secure a treatment cart on the South Unit, posing a risk of resident injury.
Deficiencies (3)
Failed to develop a complete baseline care plan for resident on enhanced barrier precautions for surgical wound and IV access.
Failed to develop a complete comprehensive care plan for residents on enhanced barrier precautions with measurable timetables and actions.
Failed to keep residents free from accident hazards by leaving a treatment cart unlocked with keys accessible.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed deficiencies related to care planning and treatment cart security during interviews | |
| CNA #1 | Confirmed treatment cart was unlocked and attempted to secure it | |
| Wound Care Nurse | Confirmed treatment cart was unlocked with keys in it |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 3
Date: Aug 8, 2025
Visit Reason
The inspection was conducted due to allegations of abuse involving CNA #28, including failure to report suspected abuse to the State Survey Agency and concerns about quality of care and resident safety.
Complaint Details
The complaint involved allegations that CNA #28 used a resident's breathing machine to administer medication to herself, was seen sleeping on duty, and ate a resident's food. The facility's investigation was unsubstantiated and no report was sent to the State Agency. Interviews revealed inconsistent findings and failure to report to the State Agency. The complaint affects all 25 residents in Hallway 1 where CNA #28 worked.
Findings
The facility failed to timely report and thoroughly investigate allegations of abuse by CNA #28, including misuse of a resident's breathing machine, sleeping on duty, and eating a resident's food. Additionally, the facility failed to ensure call lights were answered promptly for resident #44, potentially putting residents at risk.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to respond appropriately to all alleged violations, including lack of thorough investigation and preventive measures for abuse allegations.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failing to ensure call lights were answered timely.
Report Facts
Residents affected: 25
Call light response times (minutes): 19
Call light response times (minutes): 53
Call light response times (minutes): 24
Call light response times (minutes): 18
Call light response times (minutes): 20
Call light response times (minutes): 17
Call light response times (minutes): 20
Call light response times (minutes): 18
Call light response times (minutes): 18
Call light response times (minutes): 20
Call light response times (minutes): 19
Call light response times (minutes): 20
Call light response times (minutes): 23
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement comprehensive care plans and ensure adequate supervision to prevent falls, as well as issues with medical record accuracy for resident #25.
Complaint Details
The complaint investigation focused on resident #25, who fell in the restroom after being left unattended by staff. The investigation substantiated that staff failed to follow the care plan and provide adequate supervision. The resident had cognitive impairments and required substantial assistance. Staff also failed to document the fall properly in medical records.
Findings
The facility failed to implement the care plan for resident #25, resulting in a fall when staff left the resident unattended in the restroom. Additionally, the facility did not maintain complete and accurate medical records, including failure to document the fall in progress notes and incomplete SBAR forms. Staff interviews confirmed lapses in following care plans and supervision protocols.
Deficiencies (3)
Failed to implement the comprehensive care plan for resident #25 to prevent falls.
Failed to keep residents free from accident hazards and provide adequate supervision, resulting in resident #25 being left unattended and falling in the bathroom.
Failed to ensure medical records were complete and accurate; SBAR form was incomplete and progress notes did not document resident #25's fall.
Report Facts
Residents reviewed for falls: 3
Residents affected: 1
BIMS score: 6
Time left unattended: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Confirmed working with resident #25 on the night of the fall and admitted to not documenting the fall in progress notes |
| CNA #28 | Certified Nursing Assistant | Assisted resident #25 to restroom, left resident unattended, and confirmed not reviewing care plan |
| DON | Director of Nursing | Confirmed staff should follow care plans, that resident #25 should not have been left alone, and that documentation was incomplete |
Inspection Report
Deficiencies: 4
Date: Jul 2, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to creating baseline care plans for newly admitted residents within 48 hours.
Findings
The facility failed to create accurate baseline care plans within 48 hours for 4 of 5 sampled residents, omitting critical physician's orders and diagnoses, which could place residents at risk of adverse events or worsening conditions.
Deficiencies (4)
Failed to include physician's orders for R #59's antibiotic and use of oxygen in the baseline care plan.
Did not complete all sections of the baseline care plan and omitted physician's orders for R #96's antibiotic.
Did not include R #163's dementia diagnosis and physician's orders for antipsychotic medication in the baseline care plan.
Did not include physician's orders for R #110's Plaquenil and Lispro medication in the baseline care plan.
Report Facts
Residents sampled for baseline care plan: 5
Residents with deficient baseline care plans: 4
Antibiotic dosage for R #59: 500
Oxygen flow rate for R #59: 3
Antibiotic dosage for R #96: 300
Risperidone dosage for R #163: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed deficiencies in baseline care plans during interviews on 06/28/24 | |
| Social Services | Confirmed that R #110's medications were not documented in the care plan during interview on 07/01/24 |
Inspection Report
Routine
Deficiencies: 17
Date: Jul 2, 2024
Visit Reason
The inspection was conducted to evaluate compliance with healthcare regulations including medication administration, resident care plans, infection control, and safety practices.
Findings
The facility was found deficient in multiple areas including failure to notify providers of missed medication doses, inadequate care plans, incomplete physician progress notes, improper medication storage, and failure to follow infection control practices such as labeling nasal cannulas.
Deficiencies (17)
Failure to notify provider of missed medication doses for resident with urinary tract infection.
Failure to provide a homelike environment due to unreplaced burnt out light bulbs in dining room.
Failure to timely report results of abuse investigations to State Agency for two residents.
Failure to provide timely notification of hospital transfers to residents and representatives including ombudsman contact information.
Failure to provide written notice of bed hold policy to residents and representatives upon hospital transfer.
Failure to complete comprehensive Minimum Data Set assessment within 14 days of admission for one resident.
Failure to create accurate baseline care plans within 48 hours reflecting current conditions and physician orders for multiple residents.
Failure to develop and implement complete care plans addressing all resident needs including discharge plans, catheter care, and wound care.
Failure to revise care plans with current resident information and conduct interdisciplinary team care plan meetings.
Failure to keep resident free from accident hazards by not storing creams out of reach for resident with impulsivity and poor safety awareness.
Failure to ensure resident with urinary tract infection received all prescribed antibiotic doses due to medication not being received from pharmacy.
Failure to ensure appropriate care to prevent urinary tract infections including missed antibiotic doses.
Failure to ensure timely, written, signed, and dated physician progress notes at each required visit.
Failure to ensure residents had physician visits at least every 30 days for the first 90 days after admission.
Failure to store medications properly; medication cart contained loose tablets.
Failure to implement infection prevention and control program; nasal cannulas not labeled with date of change.
Failure to safeguard resident-identifiable information and maintain complete medical records; lack of documentation of food pocketing checks.
Report Facts
Missed antibiotic doses: 10
Burnt out light bulbs: 9
Residents affected: 46
Residents affected: 2
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 17
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #21 | Nurse Practitioner | Confirmed delay in entering progress notes and entering several late entries for resident #15. |
| LPN #34 | Licensed Practical Nurse | Confirmed loose tablet in medication cart and unlabeled nasal cannula tubing. |
| DON | Director of Nursing | Confirmed missed antibiotic doses, incomplete baseline care plans, failure to assess resident #266 for danger, and failure to document food pocketing checks. |
| Administrator | Facility Administrator | Confirmed expectations for timely physician notes and physician visits every 30 days for first 90 days. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan development and revision requirements, specifically focusing on whether the facility revised care plans to reflect residents' refusals of offloading and repositioning.
Findings
The facility failed to revise the care plan for one resident (R #11) to include refusals for offloading and repositioning, which could result in staff being unaware of changes in care and residents not receiving appropriate care related to their health status or healthcare decisions.
Deficiencies (1)
Failed to revise care plan for resident to include refusals for offloading and repositioning and what staff should do when refusals occur.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse #11 | Interviewed regarding resident refusal to be repositioned. | |
| CNA #11 | Interviewed regarding resident refusal to be repositioned. | |
| Wound Care Nurse #12 | Interviewed regarding resident noncompliance with offloading. | |
| Director of Nursing (DON) | Interviewed and confirmed care plan deficiencies related to refusals and noncompliance with offloading. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as part of a recertification survey and annual review to assess compliance with regulatory standards related to resident care, treatment, and assessment accuracy.
Findings
The facility was found deficient in ensuring accurate resident assessments, timely initiation of wound care upon admission, and prompt response to call lights. Specific deficiencies included inaccurate MDS documentation for one resident, delayed wound care initiation for two residents, and prolonged call light response times for another resident.
Deficiencies (2)
Failed to ensure that the MDS accurately reflected the resident's status at the time of the assessment for 1 of 3 residents sampled.
Failed to initiate wound care upon admission for 2 residents and failed to answer call lights in a timely manner for 1 resident.
Report Facts
Residents sampled for MDS accuracy: 3
Residents affected by inaccurate MDS: 1
Residents affected by wound care and call light deficiencies: 3
Admission date: Aug 1, 2023
Wound care nurse evaluation delay: 2
Call light wait times: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse | Confirmed delayed wound care evaluation and order entry for Resident #1 and delayed assessment for Resident #23 | |
| Director of Nursing (DON) | Confirmed inaccuracies in MDS diagnosis for Resident #1 and stated wound care protocols for residents admitted with wounds | |
| MDS Nurse | Admitted to including inaccurate diagnosis for Resident #1 based on hospital records without personal assessment | |
| Administrator | Confirmed one hour wait time for call light response |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a complaint survey on 2022-10-31 to investigate allegations related to delayed call-light responses and inadequate pain management for residents.
Complaint Details
The complaint investigation was based on allegations that call-lights were not answered promptly and pain medications were delayed for resident #46. The findings substantiated these complaints with documented evidence of delayed call-light responses and missed pain medication administration.
Findings
The facility failed to ensure timely response to call-lights for three residents, resulting in risks of unmet needs, incontinence, and falls. Additionally, the facility failed to provide appropriate pain management for one resident, causing unnecessary pain due to delays in medication administration.
Deficiencies (2)
Failure to ensure call-lights were answered timely for 3 residents, with documented wait times ranging from 15 to 33 minutes, exceeding the facility's expected response time of 5-10 minutes.
Failure to provide pain management for resident #46, including delays in administration of prescribed pain medications for several days after admission.
Report Facts
Call light wait times: 33
Call light wait times: 30
Pain medication administration delay: 2
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Mar 14, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to notify residents of treatment changes, abuse and neglect, failure to provide timely notifications of transfers and bed hold policies, incomplete assessments, medication errors, inadequate activities, pain management issues, medication storage, and staff training deficiencies.
Complaint Details
The complaint investigation included allegations of failure to notify residents of treatment changes, verbal abuse and neglect by staff, failure to provide timely transfer and bed hold notices, incomplete assessments, medication errors, inadequate activities, delayed pain management, unsecured medication carts, inaccurate medical record documentation, and lack of mandatory staff training on effective communication.
Findings
The facility was found deficient in multiple areas including failure to notify a resident of changes in anticoagulation medication and diagnosis, failure to protect residents from verbal abuse and neglect, failure to provide timely transfer and bed hold notices, incomplete resident assessments, medication administration errors, inadequate activity programming, delayed pain management, unsecured medication carts, inaccurate medical record documentation, and lack of mandatory staff training on effective communication.
Deficiencies (15)
Failed to notify resident R#246 of changes in anticoagulation medication and medical diagnosis.
Failed to keep residents free from verbal abuse and neglect for R#46 and R#247.
Failed to protect residents from potential abuse during investigation for 12 residents by not removing implicated staff.
Failed to provide timely written notice of transfer to residents and representatives for 4 residents.
Failed to provide written notice of bed hold policy to 4 residents and their representatives.
Failed to complete comprehensive assessment within 14 days of admission for resident R#246.
Failed to meet professional standards of quality for medication administration for resident R#7 by holding blood pressure medication without provider parameters.
Failed to provide activities to meet residents' needs for residents R#1, R#12, and R#246.
Failed to provide timely pain management for resident R#46 resulting in delay of pain medication administration.
Failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents for CNAs #11, #12, and #13.
Failed to ensure medication error rate was 5% or less for residents R#7 and R#196 due to medication hold without parameters and incomplete medication administration.
Failed to properly secure medication carts on both units, leaving medication carts unlocked and unattended.
Failed to accurately document administration of pain medication for resident R#1 and bruising related to anticoagulant medication for resident R#2.
Failed to ensure residents received or were offered pneumococcal and influenza vaccinations for residents R#1, R#28, and R#246.
Failed to ensure nursing staff completed mandatory Effective Communication training for 6 staff members.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 12
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 1
Staff affected: 3
Staff affected: 6
Residents affected: 41
Medication administration errors: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in verbal abuse and sexual harassment findings involving resident R#247 |
| RN #1 | Registered Nurse | Held blood pressure medication for resident R#7 without provider parameters |
| LPN #1 | Licensed Practical Nurse | Administered only part of medication order for resident R#196 |
| LPN #6 | Licensed Practical Nurse | Observed bruising on resident R#2 and confirmed documentation expectations |
| Dietary Manager | Dietary Manager | Interviewed regarding meal provision for resident R#46 |
| Administrator | Facility Administrator | Interviewed regarding abuse allegations, transfer notices, pain management, and staff training |
| DON | Director of Nursing | Interviewed regarding medication administration, abuse investigation, medication cart security, and staff training |
| Resident Care Manager | Resident Care Manager | Confirmed lack of transfer and bed hold notices |
| Social Services Director | Social Services Director | Confirmed transfer and bed hold notice practices and activity programming |
| Social Services Assistant | Social Services Assistant | Interviewed regarding resident activity participation |
| MDS Coordinator | MDS Coordinator | Confirmed incomplete admission assessment for resident R#246 |
| Therapy Director | Therapy Director | Confirmed missed weekly weights for resident R#20 |
| Dietician | Dietician | Confirmed missed weekly weights for resident R#20 |
| Nurse Consultant | Nurse Consultant | Confirmed lack of rationale documentation for medication dose reduction and call light response expectations |
| Human Resources | Human Resources | Confirmed lack of CNA competency evaluations |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 21, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, call light accessibility, resident council opportunities, baseline care plans, discharge planning, activities, pressure ulcer care, pain management, psychotropic medication use, medication storage, food safety, and medical record completeness.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to provide accessible call lights, lack of resident council opportunities, incomplete baseline care plans, inadequate discharge planning, insufficient activities program, improper pressure ulcer care and pain management, unnecessary psychotropic medication use, improper medication storage, food safety violations, and incomplete medical records.
Deficiencies (12)
Failed to ensure residents were treated with respect and dignity, including knocking before entering rooms, covering catheter bags, and changing soiled clothing.
Failed to provide reasonable accommodations for residents' needs and preferences by not having call lights accessible.
Failed to provide opportunity for residents to form a resident council.
Failed to include necessary care/treatment and services with goals in baseline care plans within 48 hours of admission.
Failed to develop and implement effective discharge planning with resident goals and needs.
Failed to provide an ongoing activities program designed to meet residents' interests and well-being.
Failed to provide proper care for pressure wounds and follow infection control practices during wound care.
Failed to provide necessary care to effectively manage pain before wound care.
Failed to keep residents free from unnecessary psychotropic medications, including lack of end date for PRN medication, wrong diagnosis, delayed consent, and missing assessments.
Failed to properly store medications, including not dating opened bottles and improper storage of wound care dressings.
Failed to ensure food items in pantry were labeled and dated and failed to keep deep freezer floor clean.
Failed to ensure medical records were complete and accurate, including missing physician signature on MOST form.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 37
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Confirmed multiple deficiencies including dignity, call light accessibility, baseline care plans, discharge planning, activities, wound care, pain management, psychotropic medication use, medication storage, and medical record completeness. | |
| Wound Care Nurse | Observed failing to knock before entering, improper wound care infection control, and confirmed resident pain during wound care. | |
| CNA #1 | Confirmed resident's clothes should be clean and free from stains. | |
| CNA #2 | Responded to call light request in 15 seconds. | |
| CNA #3 | Confirmed resident did not have access to call light. | |
| Administrator | Provided information about resident council, activities, and food safety. | |
| Corporate Consultant Nurse | Provided information about resident council and activities program. | |
| LPN #2 | Confirmed medication storage deficiencies. | |
| Restorative Tech | Stated not in charge of activities and described limited activity involvement. |
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