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Deficiency Records for Las Cruces Wellness and Rehabilitation LLC
A list of the most recent deficiencies for Las Cruces Wellness and Rehabilitation LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Las Cruces Wellness and Rehabilitation LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-02 | 2024-08-10 | N |
| 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. | Health | 2024-07-02 | 2024-08-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-02 | 2024-08-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-02 | 2024-08-10 | N |
| 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. | Health | 2024-07-02 | 2024-08-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-02 | 2024-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-02 | 2024-08-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-02 | 2024-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-02 | 2024-08-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-07-02 | 2024-08-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-07-02 | 2024-08-10 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-07-02 | 2024-08-10 | N |
| 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. | Health | 2024-07-02 | 2024-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-02 | 2024-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-02 | 2024-08-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-02 | 2024-08-10 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-01 | 2024-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-01 | 2024-07-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-08 | 2024-05-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-30 | 2023-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-30 | 2023-12-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-14 | 2023-04-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-14 | 2023-04-24 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-14 | 2023-04-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-14 | 2023-04-24 | N |
| 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. | Health | 2023-03-14 | 2023-04-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-14 | 2023-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-14 | 2023-04-24 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-14 | 2023-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-14 | 2023-04-24 | N |
| 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. | Health | 2023-03-14 | 2023-04-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-14 | 2023-04-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-14 | 2023-04-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-14 | 2023-04-24 | N |
| 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. | Health | 2023-03-14 | 2023-04-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-14 | 2023-04-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-14 | 2023-04-24 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-03-14 | 2023-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-14 | 2023-04-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-14 | 2023-04-24 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-08 | 2023-04-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-31 | 2022-12-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-29 | 2022-06-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-29 | 2022-06-06 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-29 | 2022-06-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-21 | 2022-02-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-21 | 2022-02-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-21 | 2022-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-21 | 2022-02-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-21 | 2022-02-21 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-21 | 2022-02-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-21 | 2022-02-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-21 | 2022-02-21 | N |
| 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. | Health | 2021-12-21 | 2022-02-21 | N |
| 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. | Health | 2021-12-21 | 2022-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-21 | 2022-02-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-21 | 2022-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-20 | 2022-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-20 | 2022-02-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-12-20 | 2022-02-03 | N |
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