F0655

D

Failure to Accurately Care Plan Admission Pressure Ulcer Within 48 Hours

Las Cruces, New Mexico Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, resulting in omission of critical wound information. Record review showed the resident was admitted on an unspecified date, and the Admission MDS documented that the resident had one unstageable pressure ulcer present on admission and required pressure ulcer/injury care. However, review of the resident’s baseline care plan, dated 02/19/26, revealed that staff did not document the presence of the pressure ulcer or the need for wound care. In an interview on 02/20/26 at 1:31 PM, the DON confirmed that the resident’s care plan did not indicate the pressure ulcer or wound care needs and stated that her expectation was for nurses to care plan wounds and necessary wound care within the first 48 hours of admission.

This deficient practice could likely result in residents not receiving appropriate care and may place residents at risk of an adverse event or worsening of their condition after admission.