Casa De Oro Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

agency, dated 08/01/25 (not within 24 hours of concern on 07/30/25), revealed the following: 1. Date of incident was 07/31/25 at 11:00 AM (discrepancy with concern of diversion on 07/30/25). 2. Resident identified was R #16. 3. CMA #16 had reported to UM #16 that she believed someone had forged her signature on a controlled drug record (an official, documented account of a controlled substance's handling, including its acquisition, storage, distribution, administration, and disposal, designed to meet the strict regulatory requirements of laws in the United States). 4. UM #16 reviewed the controlled drug records and noted additional concerns. 5. UM #16 asked residents with BIMS of 15 about taking their PRN medications and a total of three residents (names not provided) had reported that they had not asked for or been given their PRN medication. 6. LPN #16 was placed on administrative leave. 7. Pain assessments were completed on all three residents (resident's names not provided). 8. The local Sheriff department was called. E. Record review of the facility's follow-up report submitted to the state agency, dated 08/07/25, revealed the following: 1. On 07/31/25, UM #16 reported there was a discrepancy in documentation for narcotics and documentation was missing from PCC. 2. CMA #16's signature did not match her true signature. 3. LPN #16 was sent for drug testing. 4. Drug test was negative for opioid medication. 5. LPN #16 agency contract was cancelled due to failing to document narcotics. 6. CMA's and nurses were educated regarding drug diversion (the transfer of legally prescribed controlled substances from the individual they were prescribed for to another person for illicit use). 7. Follow-up report did not include the names of other residents identified as being affected by the allegation of misappropriation of narcotic medication. G.

Record review of the incidents reported to the state agency, no date, revealed the facility did not report concerns regarding misappropriation of property for R #17 or R #24.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Oro Center

1005 Lujan Hill Road Las Cruces, NM 88005

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

interview other staff who may have witnessed concerns regarding controlled medications or controlled drug records. C. On 08/20/25 at 9:24 AM, during an interview, UM #16 stated she asked R #16 and R #24 questions regarding controlled medication usage. She did not document these conversations. D. On 08/21/25 at 11:09 AM, during an interview, the administrator stated she had the DON, ADON, and UM #16 complete the investigation into alleged misappropriation of controlled medications because they are more familiar with processes related to controlled medications. E. On 08/21/25 at 11:22 AM, during a joint

interview with the DON, ADON, Administrator, and Corporate Resource Clinician, the following was confirmed: 1. The DON spot checked (a random, unplanned inspection or examination of a few items in a group to look for problems or ensure quality) controlled drug records on other units for concerns. 2. The DON was unable to state which residents' controlled drug records were reviewed. 3. The DON was unable to state what he was included in the spot check. 4. The DON did not document the spot checks. 5. The DON and ADON interviewed CMA #16, RN #16, and LPN #16. 6. UM #16 interviewed R #16 and R #24. 7. There was no documentation regarding interviews with residents. 8. No additional residents besides R #16 and R #24 were interviewed regarding use of controlled medications. 9. No additional staff members besides CMA #16, RN #16, and LPN #16 were interviewed to determine if there were witnesses or other concerns related to controlled medications. 10. The Corporate Resource Clinician stated that staff had been trained

on diversion and documentation after the concern regarding misappropriation of controlled medications was investigated. F. On 08/21/25 at 12:14 PM, during an interview, the Nurse Educator stated the following:

1. 1. The diversion training that was given to the nurses and CMAs after the concern regarding

misappropriation of controlled medications was a training that was sent to the staff via email that required them to answer questions regarding diversion. 2. Diversion training did not include reviewing controlled drug records for patterns of controlled medication administration that seemed different than resident typical patterns. 3. Staff did not receive education regarding documentation of controlled medications after the concern regarding misappropriation of controlled medications was investigated and identified documentation as an issue. G. See findings in F-F658, F-F755, and F-F842 related to controlled drug records and MAR's.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Oro Center

1005 Lujan Hill Road Las Cruces, NM 88005

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 0658 Level of Harm - Minimal harm or potential for actual harm

1. 1. He was unsure how early a narcotic pain medication that was ordered PRN could be administered, but

he thought 30 minutes early would be ok.

2. 2. He was not aware that staff had been administering R #16 and R #17’s narcotic medication

earlier than ordered.

Residents Affected - Some

3. 3. Staff were expected to document administration of all medication on the residents’ controlled drug

record and the MAR.

4. 4. Staff were expected to reassess residents for pain after administering pain medication to determine if the

medication was effective.

5. 5. Staff were expected to document the effectiveness of pain medication on the MAR.

AA. On 08/21/25 at 3:09 PM, during an interview, NP #16 stated the following:

6. 1. She looks at the MAR to determine the resident’s usage of pain medications.
7. 2. She does not look at the controlled drug records.
8. 3. If staff don’t document in the MAR, she would not know how frequently the resident used pain

medication and would not be able to accurately assess the resident’s pain management.

9. 4. If a resident requested their pain medication more frequently than ordered, that would indicate that the

resident’s pain was not controlled, and she would refer the resident to pain management.

10. 5. She had never been notified that R #16 received his pain medication more frequently than ordered.
11. 6. Giving a resident their narcotic pain medication 30 minutes early would be considered early

administration.

12. 7. She would expect staff to notify her if a resident was requesting their pain medications early more

frequently than once a week.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Oro Center

1005 Lujan Hill Road Las Cruces, NM 88005

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 0755

b. On 07/27/25 at 2:00 PM.

Level of Harm - Minimal harm or potential for actual harm

1. 2. Oxycodone every 4 hours;

a. On 08/01/25 at 7:03 AM.

Residents Affected - Some b. On 08/02/25 at 1:15 PM.

R. Record review of R #27’s Controlled Drug Record for Oxycodone HCI 5mg dated July 2025 revealed staff did not document the following:

2. 1. Oxycodone every 6 hours;

a. On 07/21/25 at 3:50 AM. b. On 07/27/25 at 2:00 PM.

3. 2. Oxycodone every 4 hours;

a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM.

S. On 08/21/25 at 2:24 PM, during an interview with the DON, he stated there was missing documentation

on R #27’s Controlled Drug Record sheets for Oxycodone.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Oro Center

1005 Lujan Hill Road Las Cruces, NM 88005

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 0760

R #18

Level of Harm - Minimal harm or potential for actual harm

F. Record review of R #18's admission documents, no date, revealed the following:

1. 1. R #18 was admitted to the facility on [DATE REDACTED].

Residents Affected - Some

2. 2. R #18 had the following diagnoses:

a. Low back pain (pain between the lower edge of the ribs and the buttock). b. Chronic pain. c. Migraine (a recurrent throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision).

G. Record review of R #18's physician's orders, dated 11/09/25, revealed an order for oxycodone 5 tablets, give two (2) tablets every 6 hours as needed for pain.

H. Record review of R #18's Controlled Drug Record for oxycodone 5 mg, dated 10/18/25 to 11/10/25, revealed the following:

3. 1. On 11/10/25 at 5:50 AM, staff documented removing two (2) tablets of oxycodone.
4. 2. On 11/10/25 at 6:02 AM, staff documented removing one (1) tablet of oxycodone (resident had just

received two (2) tablets 12 minutes before).

I. On 11/14/25 at 10:23 AM, during an interview, NP #16 stated that a resident receiving more oxycodone than ordered would be considered a significant medication error.

J. On 11/14/25 at 12:04 PM, during an interview, the DON confirmed the following:

5. 1. Administering 5 mg of oxycodone within 12 minutes of the previous dose would have been a medication

error.

6. 2. The DON was not notified that R #18 had received more oxycodone than ordered on 11/10/25.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Oro Center

1005 Lujan Hill Road Las Cruces, NM 88005

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 0842

a. On 07/21/25 at 3:50 AM.

Level of Harm - Minimal harm or potential for actual harm

b. On 07/27/25 at 2:00 PM.

1. 2. Oxycodone every 4 hours;

Residents Affected - Some a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM.

FF. Record review of R #27’s Controlled Drug Record for Oxycodone HCI 5mg dated July and August 2025 revealed staff did not document the following:

2. 1. Oxycodone every 6 hours;

a. On 07/21/25 at 3:50 AM. b. On 07/27/25 at 2:00 PM.

3. 2. Oxycodone every 4 hours;

a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM.

GG. On 08/21/25 at 2:24 PM, during an interview with the DON, he stated there was missing documentation on R #27’s Controlled Drug Record sheets for the following: 1.Oxycodone every 6 hours; a. On 07/21/25 at 3:50 AM. b. On 07/27/25 at 2:00 PM.

4. 2. Oxycodone every 4 hours;

a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM.

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

Event ID:

Facility ID:

If continuation sheet