Luna Wellness Rehab: Fall Prevention Plan Failures - NM
Federal inspectors visited the facility on August 27, 2025, and found the mat pushed against the wall on the resident's side of the room, alongside two partial side rails on his bed. The resident, identified in inspection records as Resident 24, used those rails to help himself move in bed and to steady himself when getting up. A call light was kept within his reach. When he was out of his room, staff positioned him in a common area where they could watch him.
Four separate fall prevention measures. None of them documented in his care plan.
A certified nursing assistant described all four interventions to inspectors during an interview that afternoon. She knew exactly what was in place and why. The care plan, dated June 13, 2025, reflected none of it.
LPN #28, interviewed about an hour after the CNA, looked at the care plan and confirmed the problem directly. The fall mat wasn't listed. The interventions weren't listed. "It should be care planned," she told inspectors.
The facility's MDS coordinator and Director of Nursing, interviewed together at 2:35 that afternoon, confirmed the same gap extended to at least one other resident. Neither Resident 16 nor Resident 24 had care plans that had been revised to include the fall mat intervention. Both administrators acknowledged that staff are expected to update care plans when new fall prevention measures are added.
The gap between what staff were doing and what the paperwork said matters in ways that aren't abstract. A care plan is how a facility communicates across shifts, across staff changes, across the ordinary turnover that happens in any nursing home. A night-shift aide who has never met Resident 24 relies on that document to know he needs a mat on the floor before he falls asleep. A new employee, a float, a traveling nurse — none of them would know from the care plan that the mat existed, or that the call light needed to stay within reach, or that this particular resident steadies himself on the rails before his feet hit the floor.
The inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
What the inspection doesn't say is how long the mat had been sitting undocumented beside the bed. The care plan hadn't been updated. The mat was there. Someone decided it was needed, placed it, and the paperwork never caught up.
Resident 24 was still using it when inspectors walked in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Luna Wellness Rehabilitation, LLC from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Luna Wellness Rehabilitation, LLC in Deming, NM was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records as Resident 24, used those rails to help himself move in bed and to steady himself when getting up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.