The resident, identified as R #24, was admitted on August 21 with a pressure ulcer on the sacrum — the triangular bone at the base of the spine. Staff documented the wound as a stage 2 ulcer, characterized by partial-thickness skin loss into the dermis.
Nobody provided wound care on the day of admission.
Or the next day.
Or for three more days after that.
The resident's family member told inspectors during a September 15 interview that her relative "had a wound when he got to the facility and did not receive wound care on 08/21/25." The first documented wound care didn't occur until August 25 — four days after admission.
Treatment records reveal the scope of the failure. Staff documented no wound care for the resident on August 21, 22, 23, 25, 26, or 27. The facility's Treatment Administration Record, where staff are supposed to document completed wound care, showed blank entries for all six days the resident was in the facility during that period.
Wound care orders weren't obtained until August 25, three days after the Director of Nursing's stated expectation. Those orders called for daily cleansing of the sacrum area with wound cleanser, application of collagen powder and barrier cream, and covering with silicone dressing.
The Wound Care Nurse told inspectors he was off when the resident was admitted. When he returned on August 24, he performed a skin assessment and noted the stage 2 pressure ulcer on the resident's sacrum. But even then, no treatment was provided that day.
"The WCN stated his expectation is that the floor nurses use their nursing education and obtain orders to perform treatment on residents," inspectors wrote.
The Director of Nursing confirmed during a September 16 interview that facility policy requires nurses to complete three tasks within 48 hours of admission: obtain basic care orders with the in-house provider, provide wound care, and follow up with the Wound Care Nurse.
None of this happened for R #24.
Progress notes for August revealed another problem: staff never documented that wound care wasn't completed. The absence of treatment went unrecorded, leaving no trail of the missed care.
Stage 2 pressure ulcers require consistent treatment to prevent deterioration. These wounds penetrate through the skin's outer layer into the dermis but haven't reached deeper tissue. Without proper care, they can worsen rapidly.
The facility's Minimum Data Set assessment documented that staff had completed "a clinical assessment" using "a formal assessment instrument/tool" for the pressure ulcer. But assessment without treatment provides no benefit to the resident.
Federal inspectors found that these "deficient practices could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers."
The inspection, conducted as a complaint investigation on September 16, examined three residents for pressure ulcer care. Only one — R #24 — experienced the treatment failures.
Las Cruces Village operates at 3025 Terrace Drive in Las Cruces. The facility received a citation for failing to "provide appropriate pressure ulcer care and prevent new ulcers from developing," with inspectors determining the violation caused "minimal harm or potential for actual harm."
The wound care breakdown occurred despite the facility having established protocols and a dedicated wound care nurse. Staff simply didn't follow them.
For R #24, the result was nearly a week without treatment for a painful pressure ulcer that required daily attention. The resident's family watched their relative go without basic wound care while facility staff failed to implement their own policies.
The inspection report doesn't indicate whether the delayed treatment caused the resident's condition to worsen or how long recovery took once proper care finally began.
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
- View all inspection reports for Las Cruces Village Nursing & Rehabilitation LLC
- Browse all NM nursing home inspections