Federal inspectors found that Normandie Ridge nursing home violated wound care standards for a resident with heart failure who developed the injury in August. The facility's own policy requires weekly tracking of all skin integrity issues until they heal.
Resident 71 returned from a hospital stay on August 8 with intact, dry skin on the tailbone area. Eight days later, a licensed practical nurse discovered an open wound on the left upper buttocks measuring 1.0 centimeter by 0.7 centimeter with yellow dead tissue in the wound bed.
The nurse notified a supervisor and a physician ordered wound cleansing with saline solution, medical honey application, and gauze covering. But no registered nurse completed the required wound assessment.
For the next nine days, no documented wound evaluations occurred.
During that gap, Resident 71 was rushed to a hospital emergency room on August 21 due to abnormal blood laboratory values. The resident returned to Normandie Ridge the same evening. Staff performed no skin reassessment upon return.
When a registered nurse finally documented a wound assessment on August 25, the injury had expanded dramatically. The wound now measured 5.33 centimeters in length by 1.42 centimeters in width — more than five times the original size.
The facility's electronic wound tracking system wasn't even initiated until August 25, nine days after the wound's discovery.
Resident 71 suffered from acute congestive heart failure, a condition where the heart cannot effectively pump blood throughout the body. The resident also had an irregular heart rhythm called atrial flutter. Both conditions can impair healing and increase infection risk.
Normandie Ridge's own skin management policy states that residents with impaired skin integrity must receive "necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing."
The policy specifically requires weekly tracking and documentation of all skin alterations until resolved.
During the September 26 inspection interview, the nursing home administrator confirmed that no documented wound assessment was completed between August 16 and 25. The facility provided no additional information about the care gap.
Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. Pressure wounds develop when sustained pressure cuts off blood flow to skin and underlying tissue, typically over bony areas like the tailbone.
Without proper monitoring, pressure injuries can rapidly worsen. The dead tissue found in Resident 71's wound bed on August 16 indicated the injury was already progressing beyond the superficial skin layer.
Medical honey, ordered for this resident's wound, has antimicrobial properties that can promote healing when applied properly. But effectiveness depends on regular assessment and appropriate wound care techniques.
The nine-day documentation gap occurred during a critical period when the resident was medically unstable enough to require emergency hospitalization. Residents with heart conditions face higher risks for wound complications due to poor circulation and potential medication effects.
Inspectors classified the violation as causing minimal harm or potential for actual harm. However, the dramatic wound expansion during the assessment gap demonstrates how quickly pressure injuries can deteriorate without proper oversight.
The facility failed to follow its own weekly tracking requirements and missed opportunities to intervene as the wound worsened. Professional wound care standards emphasize frequent assessment to guide treatment decisions and prevent complications.
Normandie Ridge's violation affects how the facility monitors and documents care for residents with skin breakdown. The inspection found problems with one of two residents reviewed for pressure injury care.
The administrator's acknowledgment that no wound assessments occurred for nine days confirms a significant breakdown in the facility's wound care protocols during a vulnerable period for Resident 71.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Normandie Ridge from 2025-09-26 including all violations, facility responses, and corrective action plans.