The resident, identified as Resident 8 in federal inspection records, was admitted to the facility on August 30, 2025, with a midline abdominal wound measuring 27.44 square centimeters. By the time wound care specialists finally assessed it on September 23, the wound had expanded to 36.89 square centimeters — an increase of nearly 10 square centimeters.
During those 24 days, no staff member assessed, monitored, performed dressing changes, or provided any documented care for the abdominal wound, according to the facility's Director of Nursing.
The oversight occurred despite the resident requiring maximum assistance from staff for lower body dressing, creating multiple daily opportunities for wound discovery.
Staff did notice a separate wound that developed on the resident's right calf during the stay. On September 12, nurses documented a new 3-centimeter by 3-centimeter ulcer on the resident's right posterior calf. The wound bed contained 75 percent slough — dead tissue, proteins and debris. The resident reported the area was painful to touch.
Staff promptly notified a provider, obtained treatment orders, and referred the resident to a wound clinic for the newly discovered calf wound.
Four days later, wound care specialists assessed the calf injury and found it had deteriorated significantly. The wound measured 5.5 centimeters by 2.4 centimeters and required mechanical debridement. The provider removed dead tissue down to healthy bleeding tissue, including biofilm — a slimy bacterial film that adheres to wound surfaces. The debridement extended to subcutaneous tissue containing fat, blood vessels and nerves.
Yet during this same wound consultation on September 16, specialists did not assess or address the resident's abdominal wound.
The abdominal wound finally received attention a week later during a September 23 consultation. Wound care specialists found it measured 9.02 centimeters by 4.09 centimeters by 0.3 centimeters deep, with a total area of 36.89 square centimeters. The wound bed was completely granulated with fresh, bright-red blood drainage, showing no clinical signs of infection.
The specialist noted the wound had been present for less than 30 days and recommended cleaning it with wound cleanser, applying specialized dressings, and changing the dressing three times weekly.
When questioned by inspectors on October 16, the facility's charge nurse explained that staff had discovered the leg ulcer and referred the resident to wound care for that injury. However, the nurse said staff had not been informed the resident had an abdominal wound.
The charge nurse could not locate any documentation showing staff provided care for the abdominal wound between the resident's admission and the September 23 consultation.
Two weeks later, the facility's Director of Nursing acknowledged the care failure when asked about wound services during the resident's first 24 days.
"We found the same thing that you did," the nursing director told inspectors.
When asked whether the calf ulcer should have been identified before it deteriorated to require mechanical debridement, given that staff provided maximum assistance with the resident's lower body dressing, the nursing director replied yes.
The inspection also revealed documentation problems with the resident's treatment records. The facility's Treatment Administration Record, initiated September 12 for the calf wound, failed to document the abdominal wound, the use of a wound vacuum device, or the need for twice-weekly dressing changes.
Federal inspectors classified the violations as causing actual harm to few residents. The facility's failure to provide necessary treatment and services violated federal nursing home regulations requiring facilities to ensure residents receive treatment and care in accordance with professional standards of practice.
The case illustrates how communication breakdowns and inadequate assessment procedures can lead to delayed wound care, potentially compromising healing and increasing infection risks for vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Port Washington Post Acute from 2025-11-10 including all violations, facility responses, and corrective action plans.