The resident, who requires assistance with all activities of daily living and is incontinent of bowel and bladder, also developed a deep tissue injury to his left heel and an unstageable pressure ulcer to his left lateral malleolus near his ankle.
Federal inspectors documented the case after reviewing care records and interviewing staff during a September complaint investigation. The wounds were significant enough to trigger a formal assessment change for the resident's care plan.
MDS Coordinator J told inspectors she recently completed what's called a "significant change" assessment for the resident based on his wounds. During the September 16 interview, she explained that while she doesn't physically examine wounds herself, she reviews all documentation and participates in team meetings where the wounds are discussed.
"When coding the wounds for the MDS she goes off the ARD (Assessment Reference Date), and recent documentation closest to her seven day look back period," inspectors noted.
The facility's own assessment, completed August 25, painted a stark picture of the resident's condition. The Care Area Assessment Worksheet described him as requiring assistance with incontinence care and toileting, in addition to help with all daily activities.
According to the National Pressure Injury Advisory Panel, the heel represents one of the most common locations where these injuries develop. The resident's heel injury was classified as a deep tissue injury, indicating damage beneath the skin surface that may not be immediately visible.
His coccyx wound reached stage 3 severity, meaning the injury extended through the full thickness of skin and into underlying tissue. The ankle wound was deemed "unstageable," typically indicating the injury's depth cannot be determined due to tissue coverage or other factors.
All three wounds were specifically identified as facility-acquired, meaning they developed while the resident was under the nursing home's care.
The facility maintains a skin management policy updated as recently as November 2024 that outlines specific prevention requirements. The policy mandates daily skin inspections during personal care or assistance with activities of daily living.
Staff are instructed to identify any signs of developing pressure injuries, including non-blanchable redness. For residents with darker skin, the policy requires inspecting for changes in skin tone, temperature, and consistency.
The policy specifically calls for inspection of common pressure points including the sacrum, heels, buttocks, coccyx, elbows, and other high-risk areas. It also requires washing skin after any incontinence episodes using pH-balanced cleansers.
Despite these written protocols, the resident developed multiple pressure injuries at several of the exact locations the policy identifies as requiring special attention.
The case illustrates the serious consequences when prevention measures fail for vulnerable residents. Pressure ulcers can be painful, difficult to heal, and in severe cases life-threatening. Stage 3 wounds like the one on this resident's coccyx often require weeks or months of specialized treatment.
For residents who are incontinent and require assistance with basic care, consistent repositioning and skin monitoring become critical prevention measures. The development of multiple wounds suggests potential gaps in the implementation of the facility's own prevention protocols.
The MDS coordinator's role in documenting these injuries reflects the regulatory requirement that nursing homes track and report pressure ulcer development. When residents develop new wounds or existing wounds worsen significantly, facilities must update their assessments and potentially modify care approaches.
Federal inspectors determined the case represented actual harm to the resident, affecting what they classified as "few" residents overall. The inspection was conducted in response to a complaint, suggesting concerns about care quality had been raised by family members, staff, or other sources.
The resident's case demonstrates how quickly conditions can deteriorate for individuals requiring extensive daily assistance. His need for help with toileting and incontinence care, combined with limited mobility, created the exact risk factors that pressure ulcer prevention programs are designed to address.
The wounds developed despite the facility's detailed written policies and the involvement of multiple staff members in monitoring and assessment processes. The gap between policy and practice left one resident with three painful, potentially serious injuries that will require ongoing medical attention and specialized wound care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adira Nursing and Rehabilitation from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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