Care Citations

Las Cruces Village Nursing & Rehabilitation LLC

3025 TERRACE DRIVE, LAS CRUCES, NM, 88011 · 5755562103

What CMS has flagged

  • CMS has flagged this facility for abuse citations.

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
2 / 5
Certified beds
94
Ownership type
For profit - Limited Liability company
Chain
OPCO SKILLED MANAGEMENT

Inspection findings on record (83)

Quoted exactly as CMS published them. We do not rewrite findings.

— Environmental Deficiencies

Tag 0921 · scope/severity F · potential for more than minimal harm

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0551 · scope/severity D · potential for more than minimal harm

Give the resident's representative the ability to exercise the resident's rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0573 · scope/severity D · potential for more than minimal harm

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0575 · scope/severity C · potential for minimal harm

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity C · potential for minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity E · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0727 · scope/severity F · potential for more than minimal harm

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0882 · scope/severity F · potential for more than minimal harm

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0605 · scope/severity E · potential for more than minimal harm

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity E · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity E · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0680 · scope/severity E · potential for more than minimal harm

Ensure the activities program is directed by a qualified professional.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity E · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0791 · scope/severity E · potential for more than minimal harm

Provide or obtain dental services for each resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity E · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0941 · scope/severity E · potential for more than minimal harm

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity E · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Administration Deficiencies

Tag 0949 · scope/severity E · potential for more than minimal harm

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0627 · scope/severity D · potential for more than minimal harm

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity D · potential for more than minimal harm

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Administration Deficiencies

Tag 0849 · scope/severity D · potential for more than minimal harm

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0948 · scope/severity D · potential for more than minimal harm

Ensure that paid feeding assistants have the training they need.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0603 · scope/severity D · potential for more than minimal harm

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0602 · scope/severity D · potential for more than minimal harm

Protect each resident from the wrongful use of the resident's belongings or money.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity E · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity E · potential for more than minimal harm

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity E · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0661 · scope/severity E · potential for more than minimal harm

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity E · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity E · potential for more than minimal harm

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0825 · scope/severity E · potential for more than minimal harm

Provide or get specialized rehabilitative services as required for a resident.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0943 · scope/severity E · potential for more than minimal harm

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0727 · scope/severity F · potential for more than minimal harm

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity E · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity E · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity E · potential for more than minimal harm

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity E · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity E · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity E · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity E · potential for more than minimal harm

Observe each nurse aide's job performance and give regular training.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0741 · scope/severity E · potential for more than minimal harm

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity E · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 325067