Luna Wellness Rehabilitation Llc

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the Minimum Data Set Assessment was accurate for 1 (R #24) of 3 (R #16, R #17, and R #24) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #24's admission record revealed he was admitted to facility

on 05/16/25 with the following diagnoses: 1. Chronic Peripheral [NAME] Insufficiency (is a form of venous disease that occurs when veins in your legs are damaged). 2. Type 2 Diabetes with other skin complications (happens when the body cannot use insulin correctly and sugar builds up in the blood). 3. Unilateral primary osteoarthritis left knee (is a degenerative joint condition that primarily affects one side of the body, typically

in the knees, hips, or hands). 4. Muscle weakness, generalized (occurs when your body is not able to contract your muscles properly, leading to reduced strength in one or more of your muscles). 5. Need assistance with personal care (refers to the support provided to individuals who require assistance with daily living activities). 6. Unspecified Dementia, unspecified severity, with agitation (is the loss of cognitive functioning and thinking). B. Record review of the facility's incident list, dated 05/13/25 through 08/27/25, revealed R #24 fell on the following date: 1. 05/30/25, 2. 05/20/25, 3. 07/22/25. C. Record review of R #24's physician's orders, dated 06/13/25, revealed R #24 may use 2 1/4 side rails (a type of bed rail that is typically used in medical settings to prevent patients from exiting their beds) for increased mobility and independence. D. Record review of R #24's care plan dated 06/13/25 revealed R #24 uses 2 1/4 side rails to assist in bed mobility and transfers to maximize independence. E. On 08/27/25 at 2:35 PM, during an interview, the MDS coordinator confirmed the fall with injury that occurred on 05/20/25 should have been documented in R #24's admission assessment dated [DATE REDACTED] and should have included the use of side rails to assist in bed.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Luna Wellness Rehabilitation LLC

900 West Ash Street Deming, NM 88030

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657

1. 2. 05/20/25,

Level of Harm - Minimal harm or potential for actual harm

2. 3. 07/22/25.

Residents Affected - Few

H. On 08/27/25 at 1:30 PM, during an observation of R #24's room, a fall mat was on the floor against the wall on R #24's side of the room, and 2-1/4 side rails up (a type of bed rail that is typically used in medical settings to prevent patients from exiting their beds) on top of R #24's bed.

I. On 08/2725 at 1:36 PM, during an interview, CNA #25 stated R #24 had the following interventions in place to prevent falls:

3. 1. R #24 uses side rails for mobility in bed and when he gets up R #24 side rails to assist with his balance.
4. 2. R #24 call light within reach.
5. 3. R #24 has a fall mat placed on the floor when laying in bed.
6. 4. R #24 is placed in common area so staff can keep a close eye on R #24.

J. Record review of R #24's care plan, dated 06/13/25, revealed the following:

7. 1. Staff did not document R #24 call light within reach as an intervention.
8. 2. Staff did not document the use of a fall mat as an intervention to prevent injury if R #24 falls.
9. 3. Staff did not document that R #24 is placed in a common area as an intervention to prevent falls.

K. On 08/27/25 at 2:29 PM during an interview LPN #28, she confirmed R #24's care plan does not indicate R #24's use for a fall mat, and interventions and it should be care planned.

L. On 08/27/25 at 2:35 PM, during a joint interview, the MDS coordinator and DON confirmed the following:

10. 1. R #16's and R # 24's care plan was not revised to include a fall mat next to bed.
11. 2. Staff are expected to revise the care plan when a new intervention is added for falls.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Luna Wellness Rehabilitation LLC

900 West Ash Street Deming, NM 88030

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Luna Wellness Rehabilitation LLC in Deming, NM for a deficiency under regulatory tag F-F0700 during a complaint investigation conducted on 2025-09-03.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Luna Wellness Rehabilitation LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.