The discovery occurred during Resident #681's respite stay at Austintown Healthcare Center. Hospice staff repositioned the woman and immediately informed the facility nurse about how they found her.
Nobody had assessed the wound.
Facility wound care documentation stopped after July 8, 2025, even though the ulcer continued worsening. The hospice worker who repositioned the resident stated she believed the facility failed to follow preventative measures that could have stopped the Stage I pressure ulcer from deteriorating during the respite stay.
On July 12, hospice staff documented that the right ankle wound had progressed to unstageable with 76-100% eschar coverage. The facility's wound care nurse, identified as RN #1006, told investigators during an October 16 interview that she was never notified of any changes in the wound condition.
"She was not given any new orders for the resident's right ankle wound, and the facility documentation indicated there were no changes in Resident #681's wound care," according to the inspection report.
The wound care nurse had documented the right lateral ankle wound as a suspected deep tissue injury on July 7 at 10:38 a.m. One day later, on July 8, Wound Nurse Practitioner #1007 documented the same ankle wound as a Stage I pressure ulcer.
Then the assessments stopped.
Medical record review revealed no additional wound assessments during the entire respite stay after July 8, despite the wound deteriorating to unstageable status by July 12. The progression from Stage I to unstageable represents a significant worsening that typically requires immediate medical attention and revised treatment protocols.
Federal investigators found no documented evidence that facility staff notified the resident's physician about the wound deterioration. This occurred even after RN #1000 was told by Hospice RN #1008 on July 12 about the worsening condition.
The facility's own wound care policy states that residents who are admitted with or develop skin integrity issues will receive treatment based on location, stage and drainage. The policy requires ongoing assessment and appropriate intervention as wounds change.
Pressure ulcers develop when sustained pressure reduces blood flow to skin and underlying tissue. Stage I ulcers show intact skin with redness that doesn't blanch when pressed. Unstageable ulcers involve full-thickness tissue loss where the wound base is covered by eschar or slough, obscuring the true depth of tissue damage.
The progression from Stage I to unstageable typically indicates inadequate pressure relief, positioning, or wound care management. In this case, the hospice worker's observation that the resident was sitting directly on her feet due to contractures suggests prolonged pressure on the affected ankle area.
Contractures, which involve permanent shortening of muscles or tendons, can create positioning challenges that increase pressure ulcer risk. Proper repositioning protocols become critical for residents with contractures to prevent sustained pressure on vulnerable areas.
The hospice worker who found the resident positioned on her feet had to reposition her manually. This suggests facility staff had either placed the resident in this position or failed to reposition her despite the obvious pressure being applied to her feet and ankles.
The timing reveals a four-day gap between the facility's last wound assessment on July 8 and the hospice documentation of deterioration on July 12. During this period, the wound progressed from Stage I to unstageable without facility staff documenting any observations or interventions.
Wound care nurse #1006's statement that she received no notification about wound changes indicates a communication breakdown between different care teams. The hospice staff were documenting significant wound deterioration while facility staff continued treatment protocols designed for a much less severe Stage I ulcer.
The inspection report notes this deficiency was discovered as an incidental finding during investigation of a separate complaint. This suggests the wound care failure might not have been identified without the unrelated complaint that brought inspectors to the facility.
The case illustrates how gaps in wound monitoring can allow rapid deterioration of pressure ulcers, particularly in residents with positioning challenges like contractures. The resident's condition required hospice-level care, yet facility staff failed to maintain basic wound surveillance during her respite stay.
Federal investigators classified the violation as causing minimal harm or potential for actual harm to few residents. However, the progression from Stage I to unstageable represents significant tissue damage that could have been prevented with proper monitoring and repositioning protocols.
The hospice worker's intervention in repositioning the resident and alerting facility staff prevented further deterioration, but only after the wound had already progressed to its most severe classification.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Austintown Healthcare Center from 2025-10-20 including all violations, facility responses, and corrective action plans.