WURTLAND, KY - Federal inspectors cited Wurtland Nursing & Rehabilitation for quality of care deficiencies after at least two residents developed facility-acquired pressure ulcers that investigators linked to staff failures in basic wound prevention protocols.
The complaint investigation, completed on February 11, 2025, found the facility failed to meet requirements under F-Tag F684, which governs quality of care standards for nursing home residents.
Staff Failed to Follow Pressure Prevention Protocols
According to the inspection findings, Resident 27 and Resident 10 both developed pressure ulcers after staff did not provide fundamental pressure prevention approaches. Investigators documented that staff failed to deliver adequate incontinence care and did not follow proper turning and repositioning schedules for the affected residents.
Turning and repositioning is one of the most basic and well-established interventions in long-term care. Standard clinical guidelines recommend that residents at risk for pressure injuries be repositioned at minimum every two hours. When staff neglect these schedules, sustained pressure on bony prominences restricts blood flow to skin and underlying tissue, leading to cellular damage and wound formation.
Incontinence care is equally critical. Prolonged exposure to moisture from urine or stool causes skin maceration — a softening and breakdown of the skin's protective barrier. When combined with pressure from immobility, moisture dramatically accelerates the development of pressure ulcers.
Why Facility-Acquired Pressure Ulcers Are a Serious Concern
Pressure ulcers, also known as bedsores or decubitus ulcers, are classified into four stages based on severity. Early-stage wounds involve reddened, intact skin. Advanced-stage wounds can extend through muscle and down to bone, creating life-threatening complications.
Infection is the primary danger. Open pressure wounds provide a direct pathway for bacteria to enter the body. Residents in long-term care settings — often elderly and immunocompromised — face elevated risks of sepsis, osteomyelitis (bone infection), and cellulitis when wounds are not prevented or promptly treated.
The Centers for Medicare & Medicaid Services considers facility-acquired pressure ulcers a key quality indicator. Facilities are expected to assess each resident's risk upon admission and implement individualized care plans that address mobility, nutrition, skin moisture, and repositioning needs.
What Should Have Happened
Under established nursing standards, both residents should have had documented care plans specifying repositioning intervals, skin assessments, and incontinence management strategies. Staff should have conducted routine skin checks during each shift and reported any changes in skin integrity immediately.
Proper prevention requires a coordinated approach: pressure-redistribution mattresses and cushions, scheduled position changes with documentation, barrier creams to protect against moisture, and adequate nutritional support to maintain skin health.
The fact that multiple residents developed facility-acquired pressure ulcers suggests a systemic gap in care delivery rather than an isolated incident.
Inspection Outcome
The deficiency was identified during a complaint investigation, meaning concerns were raised prior to the inspection. The citation under F684 indicates investigators determined the facility did not meet its obligation to provide care and services to maintain each resident's highest practicable physical well-being.
Wurtland Nursing & Rehabilitation is required to submit a plan of correction addressing the identified deficiencies. Families of current residents can review the full inspection report through Medicare's Care Compare website or request records directly from the facility.
For complete inspection details including all cited deficiencies, visit the [full inspection report](/facility?id=185609) on NursingHomeNews.org.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wurtland Nursing & Rehabilitation from 2025-02-11 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.