LAS CRUCES, NM - A federal inspection at Village At Northrise's Desert Willow I facility revealed significant failures in infection prevention protocols that left all 27 residents vulnerable to dangerous waterborne bacteria, including Legionella.
Lack of Qualified Infection Prevention Leadership
The most serious violation centered on the facility's failure to maintain adequate infection control leadership. During the January 30, 2025 inspection, federal surveyors discovered the facility lacked a qualified infection preventionist to oversee critical safety protocols.
The Director of Nursing revealed the infection preventionist had been on leave since January 10, 2025 due to nursing license issues. With no qualified replacement, the DON was attempting to fill the role while working to obtain certification - a significant gap in expertise during a critical time.
Federal regulations require nursing homes to designate qualified infection control personnel specifically because infectious diseases can spread rapidly through vulnerable populations. Residents in long-term care facilities face heightened risks due to age, underlying health conditions, and close living quarters.
Water Management System Failures
Perhaps most concerning, inspectors found the facility completely lacked implementation of its own water management program designed to prevent Legionella and other dangerous waterborne pathogens. Despite having a written policy requiring annual risk assessments and ongoing monitoring, facility leadership demonstrated no knowledge of actual implementation.
The Director of Maintenance, employed since October 2023, told inspectors he "was not aware of anything that was supposed to be done to prevent the growth of Legionella or other waterborne pathogens." The previous administrator who handled water management had left months earlier, with no transition of these critical responsibilities.
Legionella bacteria can grow in building water systems including pipes, faucets, and water storage tanks. When inhaled through water droplets, it causes Legionnaires' disease - a severe form of pneumonia that can be fatal, particularly for elderly individuals with compromised immune systems.
The facility's own policy outlined the need for a water management team including leadership, infection prevention staff, maintenance employees, and the Director of Nursing. However, the Administrator confirmed he was unaware of who comprised this team and had not participated in any water management meetings.
Additional Care and Safety Violations
The inspection revealed multiple other concerning practices affecting resident safety and care quality:
Wound Care Failures: Staff failed to implement physician-ordered wound treatments for residents admitted with serious conditions. One resident with seven documented wounds, including cellulitis and MRSA infections, went days without proper wound care orders or treatment documentation.
Medication Safety Issues: Inspectors found expired fish oil supplements in medication carts on the East Unit, potentially affecting all 14 residents in that area. Expired medications can lose effectiveness or develop harmful compounds over time.
Equipment Security Lapses: Treatment carts containing sterile needles, IV catheters, and various medications were left unlocked and unattended, creating potential access to dangerous medical supplies.
Call Light System Problems: Multiple residents could not access their call lights when out of bed, including one resident whose family reported he lacked the cognitive ability to use the system properly. One resident had a trash bag tied to his call light cord because it was too short to reach.
Missing Care Plan Components
The facility failed to maintain complete care plans for several residents, omitting critical information about functional abilities and care needs. Staff did not document activity preferences that residents identified as "very important," including listening to music, keeping up with news, going outside for fresh air, and participating in religious services.
Care plan meetings also lacked required interdisciplinary team participation, potentially missing important perspectives on resident needs and care approaches.
Medical Standards and Expectations
Professional standards require nursing homes to maintain comprehensive infection control programs because of residents' vulnerability to infectious diseases. Water management protocols specifically target Legionella prevention because outbreaks in healthcare facilities can be devastating.
Proper wound care requires immediate assessment upon admission and prompt implementation of physician orders. Delays can lead to infection, delayed healing, and serious complications requiring hospitalization.
Medication safety protocols mandate regular checks for expired products and secure storage of all medications and medical supplies. These measures protect residents from accidental ingestion and ensure medication effectiveness.
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services classified most violations as causing "minimal harm or potential for actual harm," though the scope affected many residents throughout the facility. The infection control violations were categorized as affecting "many" residents, reflecting the facility-wide nature of these safety gaps.
Federal nursing home regulations exist specifically to protect vulnerable residents who cannot advocate for themselves or leave unsafe conditions. When facilities fail to meet basic safety standards, residents face increased risks of serious illness, injury, or death.
Industry Context and Prevention
Effective infection control requires ongoing training, dedicated personnel, and systematic implementation of evidence-based protocols. Water management programs must include regular monitoring, risk assessments, and documentation to prevent dangerous bacterial growth.
Nursing homes nationwide have faced increased scrutiny regarding infection control practices, particularly following lessons learned during the COVID-19 pandemic about the rapid spread of infectious diseases in congregate care settings.
Proper care planning ensures residents receive individualized attention addressing their specific needs, preferences, and medical conditions. When interdisciplinary teams fail to participate fully, important aspects of care may be overlooked or inadequately addressed.
The Village At Northrise inspection highlights the interconnected nature of nursing home safety systems. When leadership gaps occur, multiple areas of care can deteriorate simultaneously, compounding risks for residents who depend on facility staff for their health and safety.
Federal inspectors will continue monitoring the facility's correction efforts to ensure proper implementation of required safety measures and protection of resident welfare.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village At Northrise (the) - Desert Willow I from 2025-01-30 including all violations, facility responses, and corrective action plans.
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