One resident's pressure injury expanded from less than a centimeter to over 14 centimeters wide while staff placed multiple layers of bedding between her and the specialized air mattress designed to prevent such wounds.
The immediate jeopardy finding was removed on February 28, but inspectors documented ongoing deficient practices affecting pressure injury care, activities programming, behavioral health planning, and staffing levels at the 68-bed facility.
Pressure Injuries Worsen Despite Treatment
A resident identified as R35 was readmitted to the facility in late 2024 after a hospitalization for spinal infection. She has diabetes, morbid obesity, and paralysis of her lower extremities, making her dependent on staff for all transfers and toileting. She is incontinent of both bowel and bladder.
Staff initially documented what they called "moisture associated skin damage" on January 8, 2025. By January 15, this had deteriorated into a stage 3 pressure injury on her tailbone. The facility continued documenting it on their non-pressure wound tracker despite acknowledging it had become a pressure injury.
The wound measurements tell the story of deterioration. On January 15, the pressure injury measured 3.4 centimeters long by 1.9 centimeters wide. By January 22, it had grown to 14.7 centimeters long. By February 5, it measured 14.1 centimeters long and 10.1 centimeters wide.
R35 developed a second pressure injury on her left thigh on the same day her first wound was reclassified. This wound was documented as stage 3 but had 100% slough tissue, which would actually classify it as unstageable according to national standards.
During the inspection, federal surveyors observed wound care being performed by a licensed practical nurse. R35 was lying on a low air loss mattress, but underneath her were multiple layers: a fitted sheet, a lift sheet, a cloth pad, an incontinence brief, and a purple incontinence liner saturated with urine.
Research shows that additional layers between a patient and an air mattress can significantly increase pressure, defeating the purpose of the specialized surface. The facility's director of nursing told inspectors that only a sheet should be under a resident on an air mattress.
The prescribed wound treatment involved Dakin solution, a chemical compound that can damage healthy tissue if not properly contained. Surveyors observed the Dakin-soaked gauze lying flat on the wound bed and coming in contact with healthy skin around the wound. When asked how she ensured the solution stayed only on the wound, the treating nurse said she "tries to form it to the wound" but wasn't sure it stayed in place during repositioning.
Missing Care Plans and Monitoring
Documentation showed R35 was supposed to be repositioned every two hours to prevent pressure. However, this intervention wasn't added to her care plan until January 30, 22 days after her first wound developed and 15 days after it became a stage 3 pressure injury.
Staff documented repositioning R35 on only 58 out of 144 opportunities between January 1 and February 17. The medication administration record showed staff marked "no" for repositioning on multiple shifts, including February 1, 5, and 14.
Despite documentation noting R35 was "noncompliant with offloading," there was no evidence staff provided education about the risks and benefits of pressure relief measures.
A second resident, R44, was admitted with a stage 2 pressure injury that had 50% slough tissue, which would indicate it was actually at least stage 3. The facility failed to complete weekly assessments per standards of practice, with no wound measurements documented for three weeks between December 18 and January 8. During this gap, the wound increased significantly in size.
Like R35, R44 also had multiple layers between her and the air mattress during the inspection.
Activities Programming Falls Short
Federal inspectors found that four residents with dementia on D hallway were not receiving meaningful activities despite detailed care plans outlining their preferences and needs.
R38, who has Alzheimer's disease, told inspectors she would like to be offered different things to do. Her care plan specified she enjoys country music, baking, being around children, balloon ball, and watching movies. She also expressed interest in religious services, morning news, and outdoor activities in warm weather.
Surveyors reviewed R38's activity participation records for December 2024 and January 2025, finding 21 days with no documented activities. During three days of observation, R38 participated only in getting her nails done one morning and watching a movie another day.
R33, who has severe cognitive impairment from Alzheimer's disease, had 22 days with no documented activities during the same two-month period. Her care plan indicated she enjoys magazines, baking, word search puzzles, and playing cards.
When R58 asked staff what there was to do, a staff member suggested she could go to the bathroom. R58 indicated that was "something to do" and told the surveyor she would like more activities.
Staff members acknowledged the problem. One certified nursing assistant said activities are not geared for residents with dementia and that she had voiced these concerns without seeing changes. Another CNA said residents with dementia need assistance and support for activities but cannot structure their own activities independently.
The Life Enrichment Specialist told inspectors she always encourages staff to include D hallway residents in activities but acknowledged that with one CNA on the hallway, there might not be time for activities.
Behavioral Health Plans Missing
R23, a cognitively intact resident with schizoaffective disorder and severe obsessive-compulsive disorder, has no behavioral health interventions in his care plan despite documented behavioral symptoms.
Staff documented R23 having behavioral symptoms of yelling, screaming, repeated movements, abusive language, or rejection of care on 23 shifts in January and 10 shifts in February. His assessment noted he has paranoid delusions at baseline.
Staff described various behaviors: becoming manic, calling people and demanding phone numbers, yelling at people, and becoming fixated on topics. One nurse said calling R23's sister helps calm him.
The director of nursing acknowledged that without a care plan, it would be difficult for staff to know what R23's behaviors are and what interventions work effectively for him. She confirmed R23 should have a behavioral care plan but does not.
Staffing Concerns Widespread
The facility triggered for low weekend staffing, prompting inspectors to begin their survey on a weekend. Only one day out of 18 reviewed met the facility's target of 3.0 hours of nursing care per patient per day.
Residents in council meetings complained that staff take too long to answer call lights and meal trays aren't passed timely due to staff unavailability.
R12, who requires two staff members and a mechanical lift for transfers, told inspectors he waited half an hour to use the commode the night before the survey, though sometimes it's over an hour. "I felt like I'm not very important," he said.
R1, who has moderate cognitive impairment from Alzheimer's disease, said she sometimes waits an hour for her call light to be answered. R316 said he had to wait half an hour that morning for assistance getting up, though sometimes the wait is an hour.
Certified nursing assistants told inspectors they cannot complete all resident care due to low staffing. One said she cannot always get to oral care for residents. Another said he must prioritize changing incontinent residents over providing oral care or range of motion exercises.
During lunch on D hallway, surveyors observed no staff in the common dining area for extended periods while residents who need supervision and assistance were eating. One resident, R38, was observed struggling to raise her spoon to her mouth five times unsuccessfully and asked the surveyor for help eating.
The nursing home administrator told inspectors the facility staffs according to census rather than resident acuity levels. Multiple department heads are certified nursing assistants who could provide direct care but rarely do so, he said.
Staff working anonymously told inspectors they don't feel there's enough staff to meet residents' needs, with one saying she sometimes works alone with over 20 residents and doesn't feel it's safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elroy Health Services from 2025-03-03 including all violations, facility responses, and corrective action plans.