F0656

D

Failure to Develop Comprehensive Care Plans for Residents With Pressure Ulcers

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

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the development and implementation of accurate, person-centered comprehensive care plans related to pressure ulcers for two residents. For one resident, the admission MDS dated 01/15/26 documented one unstageable pressure ulcer present on admission and two additional unstageable pressure injuries presenting as deep tissue injuries, also present on admission. The Care Area Assessment dated 01/21/26 indicated a need for pressure ulcer care. However, review of this resident’s care plan dated 01/16/26 showed that no care plan addressing pressure ulcers or the need for wound care had been developed.

For the second resident, the admission MDS documented one unstageable pressure ulcer present on admission, and the Care Area Assessment dated 01/06/26 indicated a need for pressure ulcer care. The resident’s care plan, initiated on 12/28/25, did not include a care plan for pressure ulcers at that time; a pressure ulcer care plan was not added until 02/20/26. During an interview on 02/20/26 at 1:33 PM, the DON confirmed that comprehensive care plans for both residents did not include plans for their pressure ulcers and the need for wound care, despite the facility’s expectation that staff complete comprehensive care plans to include pressure ulcers and wound care needs.