Inspection Reports for The Aristocrat Assisted Living
2969 Claude Dove Dr, Las Cruces, NM, 88011
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
44 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 6
Date: Jul 16, 2025
Visit Reason
Complaint Survey completed on 07/16/2025 for state requirements of NMAC 8.370.14, Regulations for Assisted Living facilities for Adults. Complaints were investigated and deficiencies were cited.
Complaint Details
Complaint # NM was investigated and deficiencies were cited related to incident reporting, resident treatment, and facility maintenance.
Findings
The facility failed to report incidents timely to the Licensing Authority, failed to treat residents with dignity and compassion during transfers, failed to store oxygen tanks securely, failed to post snacks on the weekly menu, failed to store cleaning chemicals securely, and had water damage in the boiler room ceiling.
Deficiencies (6)
Failed to report incidents within 24 hours and submit follow-up investigation reports within 5 business days to the Licensing Authority.
Failed to treat residents with dignity and compassion; staff covered resident's face with clothing and attempted unsafe transfers.
Oxygen cylinder tanks were stored unsecured on the floor, risking accidental damage or dislocation.
Weekly meal menu did not include snacks available to residents.
Cleaning supplies and hazardous chemicals were stored unsecured and accessible to residents.
Ceiling in the boiler room had extensive water damage and peeling paint.
Report Facts
Resident census: 44
Incident reporting timeframe: 24
Incident follow-up timeframe: 5
Temperature range: 35
Temperature range: 41
Hot food temperature: 140
Inspection Report
Follow-Up
Census: 47
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The inspection was an offsite Revisit/Follow-up survey completed to assess compliance with state requirements for Assisted Living for Adults.
Findings
The facility failed to ensure medication was dispensed according to physician orders for one resident, specifically regarding withholding hypertensive medication when the resident's heart rate was too low. This deficient practice could likely cause harm by increasing hypotensive effects.
Deficiencies (1)
Failed to ensure medication was dispensed in accordance with physician's orders regarding withholding hypertensive medication when heart rate was too low for one resident.
Report Facts
Census: 47
Residents reviewed: 3
Residents with medication issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Confirmed that Direct Care Staff administered medication against physician's order to withhold when heart rate was below 60 bpm |
| Director of Nursing | Director of Nursing | Conducted medication technician training on 3/21/2025 regarding reading sliding scales and withholding medication |
Inspection Report
Monitoring
Census: 32
Deficiencies: 4
Date: Dec 3, 2015
Visit Reason
On-site/Monitoring survey was completed for state requirements of 7 NMAC 8.2, Regulations for Assisted Living to assess compliance with admission, discharge, care coordination, incident reporting, fire safety, and other regulatory requirements.
Findings
Deficiencies were cited related to lack of evidence of care coordination on individual service plans for residents receiving home health services, failure to report incidents of unknown injury and missing resident property to licensing authority, unsealed penetrations in hazardous areas, and incomplete automatic fire protection sprinkler system coverage and maintenance.
Deficiencies (4)
Failed to have evidence of Care Coordination on the Individual Service Plan (ISP) for 1 of 2 residents reviewed for Home Health Services.
Failed to report to Licensing Authority incidents involving injury of unknown origin and missing resident property.
Penetrations and holes in fire rated walls and ceilings of the fuel fired water heater room were not sealed with approved fire suppression material.
Automatic Fire Protection Sprinklers were not installed in resident room closets and one bathroom; escutcheons were missing or improperly maintained on sprinklers throughout the building.
Report Facts
Residents on census list: 32
Deficiency count: 4
Incident report timeframe: 24
Plan of correction review period: 3
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 12, 2015
Visit Reason
A complaint investigation was completed for intake NM00029633 on 05/12/15 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living. The complaint was unsubstantiated, with deficiencies cited due to discovery during the survey.
Complaint Details
The complaint was unsubstantiated with deficiencies cited as a result of the investigation.
Findings
The facility failed to include documentation provided by caregivers of services related to Individual Service Plans (ISPs) for 4 of 4 resident records reviewed, indicating widespread deficient practice. Additionally, the facility failed to maintain caregiver assignment sheets specific to resident needs for 40 residents, with assignment sheets only available for April and May 2015 and notes sometimes entered late by caregivers.
Deficiencies (2)
Failed to include documentation provided by caregivers of services related to Individual Service Plans (ISPs) for 4 of 4 resident records reviewed.
Failed to keep/maintain Caregiver Assignment Sheets specific to resident needs for 40 residents.
Report Facts
Residents reviewed: 4
Residents: 40
Months of assignment sheets available: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilyn Lumsdon | Director | Signed the report |
| Administrator | Interviewed acknowledging nurse writes notes and caregivers do not |
Inspection Report
Original Licensing
Deficiencies: 2
Date: Feb 4, 2010
Visit Reason
The inspection was conducted as an original licensing survey for Aristocrat Assisted Living in Las Cruces, NM, to assess compliance with resident rights and medication administration regulations.
Findings
The facility was found deficient in maintaining a safe and sanitary living environment, specifically storing chemicals improperly in the food storage area, and in medication administration practices, including errors in medication administration records for residents.
Deficiencies (2)
Facility failed to store dishes and paper towels away from hazardous materials in the food storage room, potentially affecting 100% of residents.
Medication administration errors were identified for two residents, including incorrect dosage and timing.
Report Facts
Date survey completed: Feb 4, 2010
Surveyor ID: 22697
Resident Medication Administration Records reviewed: 5
Residents with medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Quality Assurance Supervisor | Named as responsible for chemical storage correction and medication monitoring | |
| Director | Named as responsible for chemical storage correction and medication monitoring | |
| Nurse Celia | Nurse | Participated in medication assistance in-service and medication order review |
Inspection Report
Life Safety
Census: 33
Capacity: 45
Deficiencies: 6
Date: Jan 26, 2010
Visit Reason
The inspection was a Life Safety Code survey conducted on January 26, 2010, for New Mexico Requirements for Adult Residential Care Facilities 7.8.2 NMAC.
Findings
The facility failed to ensure hazardous areas in the sprinklered building were properly separated by smoke partitions, failed to provide smoke detectors in the basement, and did not maintain adequate fire protection sprinkler system components. Additionally, smoking areas were not properly equipped with suitable ashtrays and containers.
Deficiencies (6)
Hazardous areas in sprinklered building were not separated by smoke partitions, potentially affecting nine residents.
Ceiling access panel in boiler room was missing and left open, creating a two by three feet opening.
Basement was not provided with smoke detectors; large quantity of combustible storage and exposed wood truss construction present.
Facility failed to provide at least six spare sprinklers in a cabinet for replacement purposes as required by NFPA 25.
Smoking areas lacked suitable ashtrays and containers of noncombustible material.
Fire alarm system was out of service and fire watch policy and documentation were inadequate.
Report Facts
Licensed capacity: 45
Census: 33
Residents potentially affected: 9
Opening size: 2
Opening size: 3
Fire door rating: 3
Projected delivery date: Feb 15, 2010
Projected delivery date: Feb 15, 2010
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Quality Assurance Supervisor | Named in relation to findings and corrective actions regarding hazardous areas, smoke detectors, sprinkler system, and smoking area compliance. | |
| Executive Director | Acknowledged findings at the exit conference and involved in corrective action discussions. |
Inspection Report
Annual Inspection
Census: 35
Capacity: 45
Deficiencies: 7
Date: Feb 4, 2009
Visit Reason
The inspection was an annual survey conducted on February 4, 2009, for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in maintaining building and grounds, including failure to display precautionary oxygen signs, inadequate combustion air for gas-fired equipment, and failure to ensure fire alarms, smoke detectors, and fire protection systems were properly installed, maintained, and tested. Several deficiencies potentially affected all residents and staff throughout the facility.
Deficiencies (7)
Failure to ensure precautionary oxygen signs were conspicuously displayed where oxygen is administered.
Gas-fired appliances in the laundry did not have adequate combustion air supply.
Failure to ensure fire alarm system and smoke detectors were installed, tested, and maintained in accordance with NFPA standards.
Range hood suppression system was not compliant with UL-300 standards.
Heat detector was not present in the kitchen.
Fire doors lacked required initiator devices within 5 feet on either side.
Sprinkler system spray pattern was obstructed by combustible materials stored in the basement.
Report Facts
Licensed capacity: 45
Census: 35
Date of survey: Feb 4, 2009
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged findings and stated corrective actions would be taken. | |
| Surveyor 25921 | Conducted the Life Safety Code survey and documented deficiencies. |
Inspection Report
Original Licensing
Deficiencies: 5
Date: Jan 29, 2009
Visit Reason
The inspection was conducted as the first original licensing survey for Aristocrat Assisted Living in Las Cruces, NM, to assess compliance with state regulations for adult residential care facilities.
Findings
The facility was found deficient in multiple areas including failure to document the month and year on medication administration records for residents, lack of documentation for reasons of medication omissions, and incomplete individual service plans for residents. The facility nurse and director planned corrective actions including in-service training, audits, and checklist implementation.
Deficiencies (5)
Failure to have the month and year on 1 of 5 residents' Medication Administration Records (MARs).
Failure to document reasons for omissions of medication administration for 4 of 5 residents.
Failure to have written consent for staff to assist with medication administration for 1 of 5 residents.
Failure to have a description of all services on the Individual Service Plan (ISP) for 2 of 5 residents.
Failure to follow physicians' orders for medication dosage for 2 of 5 residents.
Report Facts
Residents with deficient MAR documentation: 5
Residents with deficient ISP documentation: 2
Inspection Report
Life Safety
Census: 39
Capacity: 45
Deficiencies: 1
Date: May 9, 2007
Visit Reason
An annual Life Safety Code survey was conducted on 05/09/2007 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure that the sprinkler spray pattern was unobstructed and that the required clearance between the bottom of the sprinkler head deflector and the top of storage was eighteen inches or greater. Combustible materials were stored within the sprinkler spray pattern, obstructing it.
Deficiencies (1)
The sprinkler spray pattern was obstructed by combustible materials stored within the basement trusses, and the required clearance of eighteen inches between the sprinkler head deflector and storage was not maintained.
Report Facts
Licensed capacity: 45
Census: 39
Inspection time frame: Inspection occurred between 9:30am and 11:30am on 05/09/07
Sprinkler clearance requirement: 18
Observed clearance: 12
Truss depth: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and stated unawareness of storage obstructing sprinkler heads and committed to corrective actions | |
| Life Safety Code Surveyor | Observed deficiencies during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Mar 22, 2007
Visit Reason
The inspection was conducted due to a complaint investigation focusing on staff qualifications, resident records, medication administration, resident assessments, resident rights, food management, fire and safety training, and related regulatory compliance issues at The Aristocrat Assisted Living facility.
Complaint Details
This was a complaint investigation. The Executive Director acknowledged multiple deficiencies including lack of caregiver criminal history screening clearance, missing signatures on medication and care records, and other regulatory noncompliance.
Findings
The facility was found deficient in multiple areas including failure to comply with the New Mexico Caregiver Criminal History Screening Act for the Executive Director, lack of authenticating signatures on resident records and medication administration logs, incomplete resident assessments, failure to prohibit physical restraints, inadequate food management practices, and failure to maintain fire safety protocols. The Executive Director acknowledged these deficiencies during exit interviews and committed to corrective actions.
Deficiencies (11)
Facility failed to comply with the New Mexico Caregiver Criminal History Screening Act for the Executive Director; no clearance letter on file.
Facility failed to have authenticating signatures on entries by direct care staff on 24-hour documents and 2-hour medication checks for multiple residents.
Facility failed to have authenticating signatures on Medication Administration/Assistance Records for some residents.
Facility failed to have resident assessments reviewed and/or updated at least every six months for one resident.
Facility failed to prohibit the use of physical restraints for three residents; full bed rails were observed in use.
Facility failed to provide available snacks listed on daily or weekly meal menus.
Facility failed to keep a food waste container covered during non-use.
Facility failed to label circuit breakers to indicate the area of the facility they provide service to.
Facility failed to prohibit the use of extension cords; extension cords were observed in the facility library.
Facility failed to inquire with the Employee Abuse Registry before date of hire for two staff members.
Facility failed to use the fire alarm system or detector system in the conduct of fire drills.
Report Facts
Number of residents with missing signatures on medication records: 3
Number of residents with physical restraints observed: 3
Number of residents with incomplete six-month assessments: 1
Number of staff missing Employee Abuse Registry inquiry: 2
Date of Executive Director hire: Jul 7, 2005
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in findings related to failure to comply with caregiver criminal history screening and acknowledged deficiencies during exit interviews. | |
| Staff S15 | Acknowledged use of full bed rails in resident beds during interview. |
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