Schnepp Senior Care: Untreated Pressure Sore Worsens - MI
Resident #7, an elderly male with dementia and diabetes, arrived at Schnepp Senior Care and Rehabilitation Center in July with four documented skin wounds. The nursing admission assessment on July 22 identified a stage 1 pressure injury to his coccyx, along with bruising to his left elbow and pressure injuries to both feet.
The facility never created a treatment order for the coccyx wound.
Staff documented no skin assessments or monitoring of the pressure injury from July 22 through July 31, despite admission records clearly identifying the wound. Nursing progress notes and skin assessments during this nine-day period contained no documentation about the coccyx injury.
The attending physician examined the resident on July 24 for his admission history and physical. The doctor's note stated "Skin: negative for rash and wound." The physician made no mention of the stage 1 coccyx pressure injury documented two days earlier, nor the pressure injuries to both feet.
By August 1, nursing staff finally documented the wound's progression. A progress note that day described "resident with history of skin breakdown on buttocks/coccyx in past with scarring noted" and identified "moisture associated skin damage to coccyx and bilateral buttocks."
Staff ordered Desitin application every shift and weekly monitoring.
But the documentation gaps continued. On August 6, a skin assessment identified "one new wound" but nursing staff provided no additional details about location, size, drainage, color, or odor in the resident's health record.
During an inspection observation on August 13, a registered nurse provided wound care to the resident. Inspectors observed an open area and probable stage 2 pressure injury just to the right of the anus. The nurse took no measurements of the wound.
When inspectors interviewed the resident that same day, they asked if staff provided wound care every shift as ordered on August 1.
"Not to me they don't," he responded.
Stage 1 pressure injuries involve intact skin with non-blanchable redness. Stage 2 injuries involve partial thickness loss of skin with exposed dermis. The progression from stage 1 to stage 2 represents a significant worsening that proper treatment and monitoring could have prevented.
The resident's multiple health conditions increased his vulnerability to skin breakdown. His moderate cognitive impairment, reflected in a Brief Interview for Mental Status score of 11 out of 15, meant he could not advocate effectively for his own care needs.
The facility's electronic treatment administration record for July showed no treatment orders in place for the coccyx pressure injury identified at admission. This administrative failure meant nursing staff had no formal guidance for wound care during the critical early period when intervention could have prevented progression.
The nursing admission assessment also failed to document the stage of pressure injuries to the resident's toes or provide measurements of any skin impairments. This incomplete initial documentation established a pattern of inadequate wound monitoring that continued throughout his stay.
Federal inspectors cited the facility for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing. The violation resulted in minimal harm or potential for actual harm.
The inspection was conducted in response to a complaint. The citation affects few residents at the facility.
The resident's case illustrates how documentation failures can cascade into treatment gaps. Without proper initial assessment and ongoing monitoring, a manageable stage 1 pressure injury progressed to an open wound requiring more intensive intervention.
Pressure ulcers represent one of the most preventable complications in nursing home care. Proper positioning, nutrition, moisture management, and regular skin assessment can prevent most pressure injuries from developing or worsening.
The resident remains at the facility with an open stage 2 pressure ulcer that developed under the facility's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Schnepp Senior Care and Rehabilitation Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Schnepp Senior Care and Rehabilitation Center in St. Louis, MI was cited for violations during a health inspection on August 13, 2025.
Resident #7, an elderly male with dementia and diabetes, arrived at Schnepp Senior Care and Rehabilitation Center in July with four documented skin wounds.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.