Good Samaritan - Villisca failed to follow its own wound care policies for Resident #5, who developed two stage 2 pressure ulcers on her right sacral region, according to a federal inspection completed October 16. The facility's Director of Nursing acknowledged that no registered nurse completed required weekly assessments with measurements from April 30 through June 11.
The gap occurred because the facility's wound nurse, Staff B, took medical leave for the entire month of May. When she left at the end of April, Resident #5 had only a bruise on her right sacral region. When Staff B returned in June, the area had opened into a wound.
"When she went on leave from the facility Resident #5's right sacral region only had a bruise and when she returned in June the area was open," Staff B told inspectors.
The resident had severe cognitive impairment, scoring just 3 out of 15 on a standard mental status assessment. Her medical records showed physicians had ordered daily wound observations and dressing changes using medical honey and foam dressings.
During Staff B's absence, the facility contracted with Staff A, a certified wound nurse from an outside clinic, to assess the resident's wound. But those visits were sporadic and inadequate.
Staff A told inspectors she was supposed to see Resident #5 weekly at the wound clinic, but the resident was uncomfortable coming to the clinic. So Staff A began visiting the facility instead.
"Every time she went to the facility Resident #5 would be lying on her side," according to the inspection report. Staff A visited on May 8, May 15, and June 3, but failed to complete assessments between those dates.
The Director of Nursing acknowledged the facility's failure during interviews with inspectors. "The DON acknowledged Resident #5 did not have an assessment completed by RN with measurements and descriptions of the wound on Resident #5's right sacral region," the report states.
Weekly wound assessments with measurements are required under the facility's own policies, revised as recently as April 6. The policy states that when a pressure ulcer is identified, "the Licensed nurse records the location of the area, the measurements, and the ulcer wound characteristics."
The facility's wound data collection records from May 5 through May 31 documented no measurements of Resident #5's wound at all.
The Administrator acknowledged the oversight when questioned by inspectors. He stated "he would have expected an assessment with measurements completed weekly on all pressure ulcers."
The inspection found that while dressings appeared to be changed as ordered, the lack of proper documentation meant staff had no way to determine if the wound was healing, stable, or deteriorating during the six-week period.
Staff A from the wound clinic told inspectors the area on Resident #5's right sacral region was "unavoidable," but the facility's failure to track the wound's progression violated federal requirements for pressure ulcer care.
The facility's policy emphasizes the importance of accurate documentation, stating that pressure ulcers "should be assessed/evaluated at least weekly and documented on a Wound RN Assessment." It also requires cleansing the area before observations "to allow the wound bed and depth to be more accurately observed."
The inspection classified the violation as causing minimal harm or potential for actual harm. Good Samaritan - Villisca reported a census of 37 residents at the time of the complaint investigation.
The gap in wound monitoring occurred during a vulnerable period for Resident #5, when what started as a simple bruise progressed to an open wound without proper medical oversight. The facility now faces federal scrutiny over its wound care protocols and staffing arrangements during employee absences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Villisca from 2025-10-16 including all violations, facility responses, and corrective action plans.