The resident's family member told state inspectors on September 15 that their loved one "did not have a plan of care in place." Records confirmed their concern.
The resident had been admitted to the facility in late August with what medical notes described as a "small shallow sacral ulcer that was present on admission." The sacrum is the large triangular bone at the base of the spine, a common location for pressure sores in bedridden patients.
A physician had already written detailed orders for the wound's treatment. The orders, dated August 25, specified daily care: cleanse the sacral area with wound cleanser, pat dry, apply collagen powder and barrier cream, then cover with a silicone dressing. Staff were also instructed to provide this care "as needed" beyond the daily requirement.
Federal regulations require nursing homes to create accurate baseline care plans within 48 hours of admission. These plans serve as roadmaps for staff, ensuring residents receive appropriate care immediately while more comprehensive assessments are completed.
The facility's admission assessment, completed through the federally required Minimum Data Set, properly documented the resident's condition. Staff noted the resident had "one stage 2 pressure ulcer/injury that was present upon admission" and identified the "need for pressure ulcer/injury care."
Stage 2 pressure ulcers involve partial-thickness skin loss extending into but not through the dermis layer of skin. Without proper care, they can deepen and become life-threatening.
But the baseline care plan, dated August 22, contained no mention of the pressure ulcer. It also failed to document the resident's need for wound care, despite the detailed physician orders and the facility's own assessment findings.
The Director of Nursing confirmed the omission during an interview with state inspectors on September 16. He acknowledged that the baseline care plan "did not indicate [the resident] had a pressure ulcer" and "did not include the need for wound care."
The nursing director told inspectors his expectation was clear: "nurses should care plan the needs of residents within the first 48 hours of admission."
State inspectors concluded the failure "could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event or worsening of current condition after admission."
The deficiency affected one of three residents whose baseline care plans inspectors reviewed during the September complaint investigation. The facility received a citation for minimal harm with potential for actual harm affecting few residents.
Las Cruces Village Nursing & Rehabilitation operates at 3025 Terrace Drive in Las Cruces. The inspection was conducted in response to a complaint filed with state health officials.
The missing care plan left nursing staff without written guidance about the resident's wound care needs during the vulnerable period immediately following admission, when consistent treatment is crucial for healing and preventing infection.
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 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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