The facility's certified nursing assistants documented no skin issues on their daily bath forms from September 1 through October 1, even as the Stage 2 pressure ulcer formed and deepened. Staff only discovered the wound after the resident fell on September 27, initially misidentifying it as a skin tear from the fall.
The resident's care plan specifically required staff to monitor and reposition her every two hours because of her high risk for pressure ulcers due to decreased mobility, pain and weakness. The plan instructed staff to notify nurses immediately of any new skin breakdown during bathing or daily care.
Nobody did.
V23, a registered nurse conducting the resident's initial hospice assessment on October 4, found the pressure ulcer measuring the size of an egg, 0.1 centimeters deep and pale in color. Three days later, a wound care specialist measured it at 6.5 by 5.5 centimeters.
V24, the Doctor of Nursing Practice who treated the wound, stated the ulcer had developed three to four weeks before his October 7 visit and was not caused by the resident's fall. The wound's appearance indicated a pressure ulcer, not a skin tear as initially documented.
The Assistant Director of Nursing, V14, told inspectors she was unaware the resident had a sore on her tailbone until the morning of the fall. She acknowledged the area did not have the appearance of a skin tear.
V5, a Licensed Practical Nurse, explained that CNAs were responsible for checking residents every two hours and repositioning them. She noted the resident preferred sitting in her geriatric chair most of the day, then added she didn't know how staff would be expected to reposition someone who sits in a geriatric chair.
The facility's skin assessment policy, updated in April, established guidelines for monitoring skin breakdown and ensuring interventions are implemented. The policy's stated purpose was preventing exactly what happened to this resident.
The resident's comprehensive fall assessment documented the wound as a skin tear measuring 4.2 by 3.1 centimeters. Her hospice plan of care update from October 4 correctly identified it as a pressure ulcer to the tailbone area.
Daily CNA skin attention forms showed no documentation of developing skin issues during the month before discovery. The forms are completed during resident baths, when staff have direct visual access to check for skin breakdown.
The resident had been identified as high-risk for pressure ulcers since her care plan was initiated in May 2019. Her plan included specific interventions for turning and repositioning at least every two hours, with additional repositioning as needed or requested.
Federal inspectors found the facility failed to follow its own pressure ulcer prevention protocols for this resident. The failure resulted in actual harm as the resident developed a Stage 2 pressure ulcer that could have been prevented with proper monitoring and repositioning.
Stage 2 pressure ulcers involve partial thickness skin loss and can appear as shallow open wounds or intact blisters. They typically develop when sustained pressure cuts off blood flow to tissue, causing cells to die.
The wound care specialist's assessment three weeks after discovery showed the ulcer had progressed to 6.5 by 5.5 centimeters, significantly larger than initially measured. The depth remained at 0.1 centimeters, indicating the wound had not progressed to Stage 3 or 4.
The hospice nurse's description of the wound as "deeper than skin" and pale in color suggested compromised tissue that had been developing for an extended period. These characteristics are inconsistent with acute trauma from a fall.
Staff interviews revealed confusion about repositioning protocols for residents who spend most of their time in geriatric chairs. The LPN's statement that she didn't know how to reposition such residents suggests inadequate training on pressure ulcer prevention techniques.
The facility's own incident documentation initially classified the wound as a skin tear, demonstrating staff failed to properly assess the wound's characteristics and likely cause. This misclassification could have delayed appropriate treatment.
The resident's preference for sitting in her chair most of the day created additional pressure ulcer risk that required more frequent monitoring and specialized positioning techniques. Staff failed to adapt their care approach to address this increased risk.
Three different healthcare professionals ultimately identified the wound as a pressure ulcer rather than a skin tear, contradicting the facility's initial assessment. The wound care specialist's timeline placed the ulcer's development well before the resident's fall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Hickory Point from 2025-10-14 including all violations, facility responses, and corrective action plans.