Resident 99 was admitted on January 2, 2025, with several concerning injuries. His admission assessment documented a left foot wound, surgical incision with 36 staples, and the stage four pressure wound to his coccyx and sacrum. The Director of Nursing completed a second assessment the same day, confirming the open foot wound and stage four pressure sore.
But the baseline care plan contained no mention of wound care or skin protection treatments for any of his injuries.
"It was a new form the facility was not familiar with," the Director of Nursing told inspectors, acknowledging she had signed off on the incomplete care plan. She confirmed there was "no documented evidence of wound or pressure relieving interventions on the care plan."
The wound nurse practitioner saw the resident's foot wound on January 2 but didn't evaluate the stage four pressure sore until January 8. The Director of Nursing had no explanation for the six-day delay, especially since the wound specialist had already assessed the foot injury during her weekly visit.
Wound Nurse Practitioner 362 visits the facility once weekly, working from a list of residents from the previous week while adding new admissions or wounds based on nursing reports. She rounds with the wound nurse and follows residents with any wounds as needed after the facility places a consult.
"She was not informed of the stage four pressure wound for Resident 99," inspectors documented. The wound specialist told them she "would definitely want to see a resident with a stage four pressure wound during her rounds."
The resident was admitted while the facility was between wound nurses. The previous wound nurse had been terminated on December 30, 2024. During that transition period, the wound practitioner would round with the Director of Nursing or bedside nurses instead.
She confirmed the pressure wound had no treatment orders in place until her first assessment on January 8.
By that point, the wound had deteriorated. Initial measurements showed the stage four pressure sore was 4 centimeters by 4 centimeters. When the wound practitioner finally evaluated it six days later, it measured 6 centimeters by 5 centimeters.
The wound's classification also declined from stage four to "unstable" during this period.
The Administrator initially thought the wound had improved but acknowledged during her interview that the measurements had actually increased. She admitted that the progression from stage four to unstable represented a decline in the resident's condition.
Federal inspectors reviewed the facility's own policies during their investigation. The Pressure Ulcer/Skin Breakdown Clinical Protocol from April 2018 requires nursing staff and practitioners to assess and document pressure ulcer risk factors. Nurses must document full assessments of pressure sores, and nurse practitioners must examine skin for evidence of pressure ulcers. Physicians are supposed to order appropriate wound treatments and dressings.
The Care Plan Baseline policy from March 2022 states that baseline care plans must include instructions for effective person-centered care, including "any services and treatments to be administered by facility and personnel acting on behalf of the facility." These baseline plans are used until staff can complete comprehensive care plans.
None of these requirements were met for Resident 99's stage four pressure wound.
During a group interview on August 11, the Administrator, Director of Nursing, Regional Nurse 365, and the new Wound Nurse 345 acknowledged the facility had identified errors and non-compliance in the resident's care. They cited the ownership change and staffing transition as contributing factors.
The facility had already terminated the previous wound nurse and hired Wound Nurse 345 as part of implementing new practices.
But for Resident 99, those changes came too late. His stage four pressure wound went untreated for six critical days while proper wound care protocols sat unused and a wound specialist made her regular weekly rounds just floors away, unaware of his deteriorating condition.
The case represents the human cost when communication breaks down during staffing transitions. While administrators focused on new forms and new hires, a resident's serious wound grew larger and more unstable without the treatment that facility policies required and that medical standards demanded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kettering Heights Post Acute from 2025-08-12 including all violations, facility responses, and corrective action plans.
