Resident 3 arrived at the facility in February with a left femur fracture and a pressure wound on the coccyx. The admission evaluation documented the existing wound, and a skin assessment on February 4th classified it as a stage 2 pressure injury to the sacrum.
Stage 2 pressure injuries involve partial thickness loss of skin, presenting as shallow open ulcers with red or pink wound beds. They require careful monitoring and treatment to prevent deterioration.
By March 3rd, the wound had worsened dramatically. The skin and wound evaluation that day reclassified it as "unstageable" and described it as "deteriorated with suspected infection." Unstageable pressure injuries cannot be properly assessed because dead or dying tissue covers the wound bed.
Nobody called the doctor.
Staff 3, an LPN and Resident Care Manager, acknowledged during the November inspection that the March 3rd assessment showed the wound "appeared infected." She admitted there was "no indication Resident 3's provider was notified the wound appeared infected on 3/3/25."
The resident's care plan, created on February 4th when the wound was still manageable, was never updated after March 3rd despite the dramatic deterioration.
Staff 2, the Director of Nursing Services, confirmed the failure during her November 14th interview with inspectors. She stated "there were no new interventions added to Resident 3's care plan when the wound worsened and there were no indications the provider was notified of the wound appearing infected on the 3/3/25 wound assessment."
For seven days, the resident remained at the facility with what staff had documented as a deteriorated, potentially infected wound. No additional treatments were ordered. No doctor was consulted.
On March 10th, Resident 3 was rushed to the emergency department. Hospital records confirmed what facility staff had suspected a week earlier: the resident was admitted with an infected sacrum wound.
The progression from a manageable stage 2 pressure injury to an infected, unstageable wound requiring hospitalization illustrates the consequences of inadequate wound monitoring and communication failures. Pressure injuries can deteriorate rapidly, particularly in residents with mobility limitations from conditions like femur fractures.
The facility's own documentation created a clear timeline of neglect. The February 4th assessment established baseline care requirements. The March 3rd evaluation documented obvious deterioration and suspected infection. Yet no one acted on this critical information.
Staff 3 confirmed that according to facility protocol, providers should be notified when wounds show signs of infection. The March 3rd assessment specifically noted the wound "appeared infected," meeting the threshold for immediate physician consultation.
Instead, the resident spent a week with an untreated infected wound while facility staff continued routine care based on the outdated February care plan.
The Director of Nursing Services acknowledged the systemic failures during her inspection interview. She confirmed that when the wound assessment changed from stage 2 to unstageable with suspected infection, "there were no new interventions added to Resident 3's care plan."
This represented multiple breakdowns in basic wound care protocols. Staff documented deterioration but failed to escalate care. They identified suspected infection but never consulted medical providers. They updated no treatment plans despite obvious changes in the wound's condition.
Federal inspectors determined these failures placed residents at risk for worsening pressure ulcers. The inspection focused on pressure ulcer care after receiving complaints about the facility's wound management practices.
Resident 3's case demonstrated how documentation without action creates dangerous gaps in care. The facility had systems to assess and record wound conditions but failed to translate concerning findings into appropriate medical interventions.
The week between the March 3rd assessment and the March 10th hospitalization represented a critical window when proper notification and treatment might have prevented the need for emergency care. Instead, what staff had identified as a suspected infection was allowed to progress untreated.
Hospital records confirmed the infection that facility staff had documented but ignored seven days earlier. Resident 3's infected pressure wound required the level of medical intervention that only a hospital could provide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ashland Post Acute from 2025-11-14 including all violations, facility responses, and corrective action plans.