Las Cruces Village Nursing: Care Plan Failure - NM
The April 2026 inspection at Las Cruces Village Nursing & Rehabilitation found that the facility failed to update the care plan for a resident identified only as Resident 24, a woman living in the facility's locked memory care wing. Her family member had formally asked that Housekeeper 26 be kept away from her, both from contact and from any care role. The previous administrator and director of nursing had agreed, telling the family on December 10 that Housekeeper 26 would no longer work in the Secure Unit. When those administrators left and new ones came in, the family repeated the request to them as well.
Everyone who worked there seemed to know. The housekeeping supervisor told inspectors on April 29 that Housekeeper 26 does not work in the Secure Unit specifically because of the family's wishes. Housekeeper 26 said the same thing herself: she is no longer in the Secure Unit and is not to be in contact with or provide care to Resident 24.
The care plan said none of it.
The most recent revision to Resident 24's care plan was dated June 26, 2025. The family's request, made months before that revision, appeared nowhere in the document. The MDS nurse, the staff member responsible for entering information into residents' care plans, told inspectors she had never been informed about the family's wishes. "Any changes to resident's care should be inputted into the care plan," she said. She confirmed the care plan had not been updated.
The assistant director of nursing reviewed the care plan during an interview on April 30 and reached the same conclusion. "It should have been in R #24's care plan," she told inspectors.
What the inspection describes is a protection that existed entirely in the memories of individual employees. The housekeeping supervisor knew. Housekeeper 26 knew. The current administrator and director of nursing had been told. But the care plan, the one document that travels with a resident through staff changes, shift rotations, and administrative turnover, contained no trace of any of it.
That gap matters most in a unit designed for residents who cannot always speak for themselves or remember what protections are supposed to be in place. The family member had to repeat the request when new administrators arrived precisely because the previous agreement had never been formalized anywhere. There was no written record that could outlast the people who had made the promise.
Inspectors rated the violation as having minimal harm or potential for actual harm, the lowest level on the federal scale. The deficiency covered one of three residents whose care plans were reviewed during the complaint inspection.
The family member told inspectors they believed the housekeeper should not have been assisting Resident 24 in the first place, because she is not a certified nursing assistant and the Secure Unit requires that designation. The inspection report does not indicate whether the facility investigated whether Housekeeper 26 provided care to Resident 24 after the December agreement was made, or whether any additional falls occurred.
What the record shows is that a family did everything they were supposed to do. They reported the fall. They named the employee. They got a commitment from leadership, then repeated that commitment to the next round of leadership. The staff on the floor followed through. The care plan never caught up.
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 2026-04-30 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 6, 2026 · Our methodology
Las Cruces Village Nursing & Rehabilitation LLC in LAS CRUCES, NM was cited for violations during a health inspection on April 30, 2026.
Her family member had formally asked that Housekeeper 26 be kept away from her, both from contact and from any care role.
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.