The resident, identified in inspection records as R3, had a Braden Scale score of 12, indicating high risk for pressure ulcers. The scale measures factors like mobility and skin moisture to predict ulcer development.
R3 required mechanical lift transfers and staff assistance for basic movements like getting out of bed and using the bathroom. The care plan directed staff to check for incontinence every two to three hours and reposition the resident frequently throughout the day, with specific turns scheduled at midnight and 4 a.m.
Despite these precautions, R3 developed a stage I pressure ulcer on the sacrum measuring 1 cm x 1 cm. The wound assessment described it as an "open area."
By October 24, the ulcer had progressed to stage II and migrated to the coccyx, measuring 1 cm x 0.5 cm. The wound bed showed 100% epithelialization, indicating newly formed skin cells attempting to heal the area. Surrounding skin was denuded, meaning the protective outer layer had been removed.
Medical records showed a critical gap in wound monitoring. No assessments were documented between October 2 and October 24 — a 22-day period during which the ulcer worsened.
Licensed practical nurse LPN-A told inspectors on October 31 that R3 "normally did not have a lot of skin issues" but acknowledged staff had been monitoring "a little pressure sore on his coccyx." The nurse said she had seen the wound "a few weeks ago and it was the size of a dime."
The facility's wound care system appeared to be in disarray. RN-B admitted to inspectors: "We have some issues with our wound charting."
The registered nurse explained that leadership had discussed setting aside one day each week for two nurses to examine wounds together, but acknowledged "it had not been implemented yet."
Director of nursing confirmed the facility lacked a systematic approach to wound monitoring. When asked about procedures, the director said nurses "were supposed to complete skin checks weekly on bath day" but acknowledged that R3's required skin checks "were not being completed."
The director outlined what should happen when wounds are discovered: staff should complete a data collection form, and a registered nurse should conduct a full assessment if the initial evaluation was done by a licensed practical nurse.
But the facility's own policy contradicted the sporadic care R3 received. The Skin Assessment Pressure Ulcer Prevention and Documentation Requirements, dated April 6, 2025, specified that pressure ulcers "should be evaluated at least weekly."
The policy required registered nurses to document wound type and tissue damage on formal assessments, while licensed nurses were to record location, measurements, and wound characteristics on data collection forms.
R3's case highlighted the human cost of inconsistent wound care protocols. The resident's care plan recognized multiple risk factors: reduced physical mobility, the need for frequent repositioning, and vulnerability to skin breakdown. Staff had been provided specific tools — pressure-reducing mattresses and protective boots for nighttime use.
Yet the very wound monitoring system designed to prevent deterioration had failed.
Stage I pressure ulcers affect only the skin's surface and typically appear as persistent red areas that don't blanch when pressed. Stage II ulcers penetrate deeper, creating partial-thickness wounds that can appear as shallow craters or fluid-filled blisters.
The progression from stage I to stage II represents a significant escalation in tissue damage and healing complexity.
R3's ulcer developed despite a care plan that specifically identified "alteration in skin integrity related to reduced physical mobility" as a primary concern. The plan included detailed positioning schedules and pressure-relief equipment precisely because the resident's condition made wounds likely.
The 22-day documentation gap meant staff couldn't track whether interventions were working or if the wound was responding to treatment. Without regular measurements and descriptions, nurses couldn't adjust care plans or escalate treatment when the ulcer began deteriorating.
Federal regulations require nursing homes to provide wound care that promotes healing and prevents new wounds from developing. Facilities must ensure residents who enter without pressure ulcers don't develop them unless clinically unavoidable.
The inspection found that R3's wound progression occurred while basic monitoring requirements went unfulfilled, raising questions about whether the deterioration was truly unavoidable or the result of inadequate oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Blackduck from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
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