The woman fell from her bed at Las Cruces Village Nursing & Rehabilitation at 12:50 AM on June 15, 2025. Staff didn't find her until 4:01 AM, according to video footage from a motion-activated camera in her room that federal inspectors reviewed during a September complaint investigation.
The resident cannot walk, speak, use a call light, or get up on her own due to her Parkinson's disease with dyskinesia. Video shows she was heard shrieking and moaning at 3:59 AM, just two minutes before a certified nursing assistant finally entered her room.
Nobody had checked on her for more than six hours.
Facility video revealed staff last entered the woman's room at 9:46 PM on June 14. They didn't return until 4:01 AM on June 15, when they discovered her on the floor beside her bed.
The facility's administrator confirmed to inspectors that staff are expected to conduct rounds every two hours, and more frequently for residents who cannot call for help independently. She acknowledged the resident "could have been on the floor for 5 hours" and confirmed the woman cannot push the call light, call out for help, or get up on her own.
The resident's daughter learned about the fall when the nursing home called her on the morning of June 15. She asked her brother to review the video footage from her mother's room, which revealed the extended time on the floor.
"R #8 is not able to use the call light," the daughter told inspectors during a September 8 interview. "R #8 is nonverbal and not able to call out for help because she has Parkinson's disease. R #8 is not able to ambulate on her own."
The resident was admitted to Las Cruces Village with multiple conditions that make her particularly vulnerable. Her medical record lists Parkinson's disease with dyskinesia and fluctuations, repeated falls, generalized muscle weakness, dependence on a wheelchair, disorientation, and abnormal gait and mobility. She requires assistance with personal care.
Parkinson's disease with dyskinesia involves the typical symptoms of tremors, rigidity, and slow movements, combined with involuntary writhing movements. The fluctuations mean symptoms vary unpredictably throughout the day.
Federal inspectors found the facility failed to protect the resident from neglect by not conducting the required safety checks. The violation carries a designation of "minimal harm or potential for actual harm" affecting "few" residents, but inspectors noted the deficient practice "could likely result in the resident suffering from lack of care, having anger, fear, and anxiety as a result of their neglect, and not getting the help she needs in a timely manner."
The September 16, 2025 inspection was conducted in response to a complaint. Inspectors reviewed records for three residents as part of their neglect investigation, finding violations affecting one of the three.
Video evidence proved crucial in documenting the extent of the neglect. The motion-activated camera in the resident's room captured the timeline: her fall at 12:50 AM, her distressed vocalizations at 3:59 AM, and staff finally discovering her at 4:01 AM.
The administrator's admission during her September 9 interview confirmed the facility's own policies were violated. She stated her expectation and the standard practice require staff to conduct rounds every two hours, with more frequent checks for residents who cannot summon help independently.
She acknowledged after viewing the facility's video that staff had not entered the resident's room from 11:00 PM on June 14 until 4:00 AM on June 15. The timeline means the resident was alone and vulnerable for at least five hours, including the three hours and ten minutes she spent on the floor after falling.
The case highlights the particular vulnerability of residents with conditions like Parkinson's disease, who cannot advocate for themselves when emergencies occur. Without the ability to speak, move independently, or operate a call light, such residents depend entirely on staff following protocols for regular safety checks.
Las Cruces Village Nursing & Rehabilitation is located on Terrace Drive in Las Cruces. The facility was required to submit a plan of correction following the inspection, though the specific corrective measures were not detailed in the inspection report.
The daughter's decision to have her brother review the room's video footage revealed the full scope of her mother's ordeal. Without that family review of the recording, the extended time on the floor might never have been discovered or documented.
The resident's medical conditions created a perfect storm of vulnerability. Her Parkinson's disease rendered her nonverbal and unable to move independently. Her history of repeated falls made regular monitoring even more critical. Her need for assistance with personal care meant she depended on staff for basic safety and dignity.
The violation occurred despite clear facility policies requiring regular rounds. The administrator's acknowledgment that staff should check more frequently on residents who cannot call for help independently suggests the facility was aware of this resident's particular needs yet failed to meet them.
Federal regulations require nursing homes to protect residents from all forms of neglect. The failure to conduct required safety rounds left this vulnerable woman without the basic monitoring needed to ensure her safety and wellbeing during the overnight hours when she was most at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Cruces Village Nursing & Rehabilitation LLC from 2025-09-16 including all violations, facility responses, and corrective action plans.
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