Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
504% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 3
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to allegations of neglect involving a staff member posing as a licensed practical nurse (LPN) without proper credentials, including missed medications and improper care practices.
Complaint Details
The complaint investigation was substantiated as the facility failed to report neglect allegations involving Staff Member #1 who used false credentials and provided substandard care. The facility did not report these allegations to the State Agency as confirmed by the Director of Nursing during the interview.
Findings
The facility failed to report allegations of neglect related to Staff Member #1 who worked with false credentials and demonstrated inadequate nursing skills, including medication errors, improper IV administration, and failure to complete required documentation. The facility also failed to report these allegations to the State Agency.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Employed a staff member as an LPN without a license or appropriate skill set, resulting in inappropriate care including improper handling of a foley catheter causing pain to a resident.
Staff member gave wrong medications, attempted improper IV starts, and had poor documentation.
Report Facts
Residents present during inspection: 121
Staff Member #1 employment period: Worked from 06/10/24 to 08/28/24 using false credentials
Resident #2 discharge date: Discharged on 09/09/25
Resident #1 discharge date: Discharged on 09/09/24
Medication frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member #1 | Unlicensed LPN (posing as LPN) | Named in multiple findings for neglect, improper medication administration, and falsifying credentials |
| LPN #1 | Licensed Practical Nurse | Interviewed and reported concerns about Staff Member #1's performance and documentation |
| CNA #1 | Certified Nursing Assistant | Interviewed and reported Staff Member #1's poor work habits and improper IV attempts |
| ADON | Assistant Director of Nursing | Interviewed and confirmed Staff Member #1's lack of license and skill deficiencies |
| DON | Director of Nursing | Interviewed and confirmed failure to report allegations to State Agency |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely written notification to residents and their representatives about transfers or discharges, failure to notify about bed hold policies, inaccurate Minimum Data Set (MDS) assessments, incomplete baseline care plans, and failure to provide appropriate treatment and care according to physician orders.
Complaint Details
The complaint investigation focused on failure to notify residents and representatives in writing about transfers, discharges, bed hold policies, and failure to provide accurate assessments and care plans. The investigation found substantiated deficiencies in these areas.
Findings
The facility failed to provide written transfer and discharge notices including appeal rights to residents and their representatives, failed to notify the Ombudsman, did not provide written bed hold notices, had inaccurate MDS assessments for several residents, failed to complete baseline care plans within 48 hours of admission, and did not implement wound care orders or notify providers about skin damage for certain residents. These deficiencies could result in residents and families being uninformed and residents not receiving appropriate care.
Deficiencies (5)
Failure to provide timely written notification to residents and representatives about transfers or discharges including appeal rights and Ombudsman contact information.
Failure to provide written notice of bed hold policy duration to residents or representatives upon hospitalization.
Inaccurate Minimum Data Set (MDS) assessments for residents, including failure to document pressure ulcers, falls, and skin damage.
Failure to complete accurate baseline care plans within 48 hours of admission, omitting diagnoses, wounds, and feeding tube information.
Failure to implement convalescent care orders for wounds, assess wounds upon admission, and notify provider of Moisture Associated Skin Damage (MASD).
Report Facts
Residents affected by transfer/discharge notification deficiency: 5
Residents reviewed for hospitalization bed hold notice deficiency: 4
Residents reviewed for MDS assessment accuracy: 5
Residents reviewed for baseline care plan accuracy: 3
Residents reviewed for wound care and treatment deficiency: 2
Size of Moisture Associated Skin Damage (MASD): 6
Number of wounds on resident #11 at admission: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #16 | Registered Nurse | Confirmed no written transfer notices provided to residents or representatives |
| CNA #16 | Certified Nursing Assistant | Described protocol for notifying nurse of skin changes |
| DON | Director of Nursing | Confirmed lack of written transfer notices and failure to notify Ombudsman |
| MDS Coordinator | Confirmed inaccuracies in Minimum Data Set assessments and baseline care plans | |
| ADON | Assistant Director of Nursing | Confirmed failure to document wound care and assessments for resident #11 |
Inspection Report
Routine
Census: 27
Deficiencies: 16
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to timely report investigations of abuse and medication diversion, inadequate resident notification of transfers and discharges, inaccurate resident assessments and care plans, failure to implement wound care orders, unsafe medication storage, lack of infection control program including water management, and inadequate call light systems.
Deficiencies (16)
Failed to timely report results of investigations of alleged medication diversion and injuries of unknown origin to the State Agency within five days.
Failed to notify residents and representatives in writing of transfers and discharges including appeal rights and ombudsman contact information.
Failed to provide written bed hold notices for residents hospitalized.
Failed to ensure accurate Minimum Data Set (MDS) assessments for residents.
Failed to create accurate baseline care plans within 48 hours of admission for residents.
Failed to develop accurate, person-centered comprehensive care plans and ensure interdisciplinary team participation.
Failed to implement convalescent care orders and notify providers of skin condition changes.
Failed to obtain wound care orders and provide wound care for pressure ulcers present on admission.
Failed to keep treatment carts locked when not supervised, exposing residents to potential injury.
Failed to have physician orders and clinical justification for condom catheter use.
Failed to change nasal cannula within 7 days as per professional standards.
Failed to ensure medications in medication carts were not expired.
Failed to maintain an infection prevention and control program including a water management plan to minimize Legionella and other pathogens.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failed to ensure call light pull cords were accessible to residents when not in bed.
Resident received psychotropic medication (Remeron) without a medically appropriate diagnosis.
Report Facts
Residents affected: 27
Residents affected: 14
Residents affected: 6
Residents affected: 5
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #16 | Registered Nurse | Confirmed expired medication in medication cart and lack of transfer notices |
| DON | Director of Nursing | Confirmed multiple deficiencies including lack of transfer notices, wound care orders, infection control program, and staffing posting |
| LPN #8 | Licensed Practical Nurse | Confirmed unlocked treatment cart |
| CNA #16 | Certified Nursing Assistant | Described protocol for notifying nurse of skin changes |
| MD #1 | Maintenance Director | Confirmed call light cords were too short and no modifications available |
| Social Services Worker | Responsible for inviting staff to care plan meetings and described attendance |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 4
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a complaint survey completed on 11/15/24 to investigate a complaint intake ID related to the Village at Northrise - Desert Willow II assisted living facility.
Complaint Details
Complaint intake ID was investigated during the survey completed on 11/15/24. Deficiencies were cited related to personnel records, resident activities, medication administration, and staff dementia training.
Findings
The facility was found deficient in multiple areas including failure to maintain personnel records for direct care staff, lack of recreational and social activities for residents, incomplete medication administration records for several residents, and failure to ensure staff completed required dementia training. These deficiencies could likely result in harm to the 21 residents identified on the census.
Deficiencies (4)
Failure to maintain personnel records for 2 direct care staff members, risking harm to 21 residents.
Failure to provide recreational and social activities and post an activities calendar for residents.
Incomplete Medication Administration Records (MAR) for 6 residents, including missed documentation of medication doses and pain medication administration.
Failure to ensure staff completed 12 hours of annual dementia training as required for memory care unit staff.
Report Facts
Residents identified on census: 21
Direct Care Staff (DCS) missing personnel records: 2
Residents with incomplete MARs: 6
Hours of dementia training required: 12
Staff missing dementia training: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Named in findings related to missing personnel records and dementia training | |
| License Practical Nurse (LPN) #1 | Interviewed regarding resident activities and medication administration | |
| Director of Health and Wellness | Responsible for monitoring corrective actions and medication audits |
Inspection Report
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development of individualized discharge goals and needs for residents.
Findings
The facility failed to develop care plans addressing the individualized discharge goals and needs for 3 residents reviewed, which could prevent a safe transition from the facility to the residents' post-discharge settings.
Deficiencies (1)
Failure to develop a care plan on the resident's individualized discharge goals and needs for 3 residents (R #11, R #12, and R #13).
Report Facts
Residents reviewed for discharge planning: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services (SS) | Confirmed lack of documentation of residents' discharge goals or needs in care plans during interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly document required discharge information for a resident.
Complaint Details
The complaint investigation found that the facility did not provide documentation for the discharge of resident #122, and the Administrator confirmed the lack of documentation during an interview on 11/06/23.
Findings
The facility failed to have the physician document the required discharge information in the medical records for one resident discharged on 05/23/23, including orders from the physician, basis for transfer, unmet needs, and how the receiving facility met the resident's needs.
Deficiencies (1)
Failure to have the physician document the required discharge information in the resident's medical records.
Report Facts
Residents affected: 1
Inspection Report
Routine
Deficiencies: 17
Date: Nov 6, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide written Medicare Non-Coverage notices, timely transfer notifications, accurate baseline care plans, proper pressure ulcer care, medication administration errors, staff competency and training deficiencies, unsafe medication storage, unsanitary food storage conditions, and non-functioning call light systems.
Deficiencies (17)
Failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to a resident.
Failed to provide timely written transfer notices to residents and representatives.
Failed to provide written notice of bed hold policy to resident or representative.
Failed to create an accurate baseline care plan reflecting resident's current condition within 48 hours of admission.
Failed to develop and implement a comprehensive person-centered care plan including all resident needs.
Failed to ensure nursing staff immediately knew residents' code status for CPR.
Failed to provide appropriate pressure ulcer care including prescribed air mattress.
Failed to keep treatment cart locked when unattended, posing accident hazard.
Failed to provide appropriate Foley catheter care including tubing off floor and current physician order.
Failed to continuously administer enteral tube feeding per physician's orders.
Failed to ensure nursing staff competency in weighing residents.
Failed to complete performance evaluations for nursing assistants annually.
Failed to provide behavioral health training to staff despite resident aggression incident.
Failed to ensure residents were free from significant medication errors including missed doses of metoprolol succinate ER.
Failed to properly store medications including disposal of expired Shingrix vaccine.
Failed to maintain sanitary food storage and preparation areas including dirty floors, unlabeled spices, and presence of a plunger in dry storage.
Failed to maintain functioning call light systems in resident bathrooms and rooms.
Report Facts
Residents sampled for beneficiary notices: 3
Residents affected by NOMNC deficiency: 1
Residents reviewed for hospitalization transfer notices: 2
Residents affected by transfer notice deficiency: 2
Residents reviewed for baseline care plan accuracy: 2
Residents affected by baseline care plan deficiency: 1
Residents reviewed for comprehensive care plans: 2
Residents affected by care plan deficiency: 1
Residents reviewed for code status: 3
Residents affected by code status deficiency: 1
Residents reviewed for pressure ulcers: 3
Residents affected by pressure ulcer care deficiency: 1
Residents in East Unit: 10
Residents reviewed for urinary catheter care: 2
Residents affected by catheter care deficiency: 1
Residents reviewed for tube feeding: 1
Employees sampled for weighing competency: 3
Employees sampled for performance evaluations: 3
Residents reviewed for behavioral health training: 1
Residents reviewed for medication errors: 3
Residents affected by medication errors: 1
Expired vaccine vials found: 8
Residents eating food prepared in kitchen: 18
Residents reviewed for call light functionality: 3
Residents affected by call light deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed failure to provide written NOMNC and transfer notices | |
| Social Services Director | Confirmed failure to provide transfer notices | |
| Business Office Manager | Confirmed failure to provide bed hold policy | |
| LPN #31 | Licensed Practical Nurse | Provided information on resident #175 fall risk and catheter care |
| Occupational Therapy Assistant | Provided information on resident #175 transfer needs | |
| Director of Therapy | Provided information on resident #175 transfer needs | |
| Interim Director of Nursing | Interim DON | Confirmed baseline care plan issues and medication errors |
| Administrator in Training | Confirmed failure to provide written NOMNC | |
| CNA #11 | Certified Nursing Assistant | Confirmed pressure ulcer mattress issue |
| Wound Care Nurse | Confirmed pressure ulcer mattress issue | |
| LPN #32 | Licensed Practical Nurse | Confirmed treatment cart unlocked |
| Dietician | Expressed concerns about resident weights | |
| Executive Director | Confirmed lack of staff competencies and performance evaluations | |
| ADON | Assistant Director of Nursing | Confirmed behavioral incident and lack of staff training |
| LPN #7 | Licensed Practical Nurse | Witnessed resident attack on CNA #20 |
| Dietary Manager | Confirmed unsanitary kitchen conditions |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility operations, and safety at Northrise Wellness & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate accommodations for bariatric residents, lack of resident council formation, failure to provide timely transfer and bed-hold notices, incomplete assessments and care plans, insufficient activities, inadequate staffing levels, incomplete nursing competencies, incomplete resident records, and lack of a qualified infection preventionist.
Deficiencies (13)
Failed to ensure residents were treated with respect and dignity, including failure to assist with ADLs, bathe according to schedule, and speak respectfully.
Failed to provide reasonable accommodations for a bariatric resident by not providing a bariatric bed.
Failed to give residents the opportunity to form a resident council due to absence of an Activities Director.
Failed to provide timely written notice of transfer and bed-hold notice to resident and representative.
Failed to complete comprehensive assessments within 14 days of admission for some residents.
Failed to complete and submit Minimum Data Set (MDS) discharge assessments in a timely manner.
Failed to develop and implement accurate baseline care plans within 48 hours of admission for multiple residents.
Failed to provide discharge summary documentation for a discharged resident.
Failed to provide individualized activity programs for residents due to absence of an Activities Director.
Failed to maintain adequate nursing staff levels to meet resident needs, with documented shortages of CNAs.
Failed to perform CNA competencies for one CNA staff member.
Failed to maintain complete and accurate resident records, including missing skin assessments, shower documentation, and incomplete MOST forms without required signatures.
Failed to designate a qualified infection preventionist with required certifications and training.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 5
Residents affected: 26
Staffing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #21 | Certified Nursing Assistant | Named in finding for inappropriate communication with resident and lack of CNA competencies |
| Director of Nursing | Director of Nursing (DON) | Confirmed multiple deficiencies including dignity issues, care plan inaccuracies, and acting infection preventionist without required certifications |
| Administrator | Facility Administrator | Confirmed staffing shortages, lack of activities director, and incomplete MOST forms |
| LPN #5 | Licensed Practical Nurse | Confirmed shower schedule for resident R#84 |
| LPN #21 | Licensed Practical Nurse | Reported lack of nursing staff schedule |
| LPN #22 | Licensed Practical Nurse | Reported CNA staffing shortages |
| Director of Social Services | Director of Social Services (DSS) | Confirmed lack of transfer and bed-hold notices for resident R#17 |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 24, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 24, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
Date: May 20, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 16, 2020
Visit Reason
An onsite surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the Covid 19 infection prevention and control survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 11, 2020
Visit Reason
Revisit/Follow-up survey conducted to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 03/11/2020.
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 3
Date: Dec 5, 2019
Visit Reason
A full onsite annual survey was conducted to assess compliance with state regulations for assisted living facilities, including admission/discharge agreements, medication administration, and fire safety.
Findings
The facility was found deficient in ensuring admission/discharge agreements included required refund policies and termination clauses, documenting coordination of care on individual service plans, properly documenting PRN medication administration and results, and conducting fire drills using the fire alarm system.
Deficiencies (3)
Admission/Discharge agreements lacked required refund policy for death, termination clause, and evidence of coordination of care on individual service plans.
Medication Administration Records (MAR) failed to document date/time and results of PRN medications given.
Fire drills were conducted without utilizing the fire alarm system, risking alarm failure and inadequate staff/resident response.
Report Facts
Residents at risk: 22
Fire drills without alarm use: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 8, 2010
Visit Reason
A complaint investigation was conducted for intake #27599.
Complaint Details
Complaint investigation was unsubstantiated.
Findings
The investigation concluded that the complaint was unsubstantiated.
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 23, 2008
Visit Reason
An annual unannounced Life Safety Code survey was conducted to assess compliance with New Mexico State Regulations governing Adult Residential Care Facilities.
Findings
The facility was found to be in compliance with the Life Safety Code portion of New Mexico State Regulations, and no deficiencies were cited.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 18, 2008
Visit Reason
This is the original licensing inspection for Village at Northrise - Desert Willow I facility in Las Cruces, NM.
Findings
The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2, with no deficiencies noted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2008
Visit Reason
A complaint survey was initiated on 2008-06-02 and completed on 2008-06-10 to investigate compliance with Requirements for Adult Residential Care Facilities 7.8.2 NMAC.
Complaint Details
A complaint survey was initiated on 2008-06-02 and completed on 2008-06-10. The facility was found to be in compliance with the requirements.
Findings
The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2, with no deficiencies identified.
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 12, 2006
Visit Reason
An annual life safety code survey was conducted on 12/12/06 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure circuit breakers located in electrical panels were identified in a manner that allows for quick identification of a particular circuit. Specifically, two circuit breaker panels in the laundry area had circuits not clearly identified to correspond to the panel listing.
Deficiencies (1)
Circuit breakers located in electrical panels were not identified in a manner that allows for quick identification of a particular circuit.
Report Facts
Circuit breaker panels observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Participated in the tour of the facility and explained how circuits are identified on the panels. | |
| Administrator | Participated in the tour of the facility during the inspection. | |
| Surveyor 17700 | Surveyor | Conducted the inspection and cited the deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 12, 2006
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for the Village at Northrise-Desert WI facility, including review of resident records, nutrition, building maintenance, and other regulatory requirements.
Findings
The facility was found deficient in several areas including incomplete staff signatures on medication administration records, missing admission agreements for some residents, lack of TB test results for some staff, failure to maintain proper freezer temperatures, and unsafe electrical conditions in the kitchen. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (6)
Staff entries on the medication administration record were not signed for 1 of 3 residents.
Facility failed to have admission agreements for 2 of 5 residents.
Facility failed to have TB test results on file for 2 of 3 staff members.
Facility failed to maintain freezer temperature at 0 degrees Fahrenheit or below; freezer was observed at +15 degrees Fahrenheit.
Circuit breaker box in the kitchen did not have the protective cover installed, exposing high voltage electrical connections.
Facility failed to post between meal snacks on the weekly menu.
Report Facts
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Program Manager | Acknowledged lack of staff signatures on medication administration records and other deficiencies during interviews | |
| Business Office Manager | Acknowledged missing admission agreements during interview | |
| Staff Development Coordinator | Audited employee files for TB test results and confirmed missing documentation | |
| Maintenance Supervisor | Responsible for maintenance issues including cleaning freezer filters and addressing electrical safety concerns | |
| Admissions Director | Responsible for completing admission agreements as part of corrective action |
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