Life Care Center of Mount Vernon staff discovered the resident's significant foot injuries only after the compression stocking was finally removed during a November complaint investigation. The resident faced risk of limb loss.
The resident had undergone right total knee replacement surgery and returned to the facility on October 23, 2025. Staff conducted a readmission skin assessment that day but never removed the compression stocking from the resident's right leg to examine the skin underneath.
Multiple staff members knew the resident was refusing to allow removal of the compression stocking. But nobody contacted the resident's physician about the refusal, and no one documented the situation in the medical record.
Staff F, a nurse, told investigators during an interview on November 18 that other day shift nurses had informed them the resident's family didn't want the stocking removed. "I just don't think they knew what to do, I really don't know why they never got a better order or cleared it up," Staff F said.
The nurse assumed someone had called the doctor for clarification but confirmed they personally never contacted the provider about removing the compression stocking.
Staff D, an LPN and Resident Care Manager who conducted the October 23 readmission assessment, acknowledged they never removed the compression stocking during the skin evaluation. Staff D confirmed the resident's medical record contained no communication with the physician regarding the refusal of care.
The resident was taking blood thinners and faced elevated risk for blood clots following the knee surgery. Yet the facility never incorporated post-surgical monitoring into the resident's care plan.
Staff B, an RN serving as outgoing Director of Nursing Services, was aware the resident had been refusing stocking removal after the surgery. Staff B knew about the blood thinner medication and clot risk but confirmed the resident's care plan lacked any assessment or monitoring protocols for post-knee replacement complications.
"There was no documentation of the refusals, and no licensed staff had contacted the provider," Staff B told investigators.
The compression stocking had become dangerously tight around the resident's leg. When Staff F finally observed the resident's foot, they noted the concerning appearance but took no immediate action to remove the stocking or contact medical providers.
During a joint interview on November 18, facility Administrator Staff A and incoming Director of Nursing Services Staff C acknowledged their investigation revealed systemic failures. The facility had demonstrated "a lack of notification, documentation, care planning, monitoring and assessment of Resident 1's right foot post-surgical procedure."
This cascade of oversights resulted in the resident developing significant wounds to their right foot that required immediate hospitalization and surgical intervention to repair the damage.
The resident's condition had deteriorated to the point where medical professionals determined there was risk for loss of the limb. What began as routine post-surgical care had escalated to a limb-threatening emergency due to staff assumptions and communication breakdowns.
The facility's failure extended across multiple areas of basic care. Staff didn't document refusals of care, didn't communicate with physicians about care barriers, didn't modify care plans for post-surgical needs, and didn't conduct proper assessments of surgical sites.
Each staff member interviewed pointed to someone else handling the situation. Day shift told evening shift the family had preferences. Evening shift assumed day shift was managing physician communication. The Resident Care Manager conducted assessments without examining the surgical area. The Director of Nursing knew about risks but didn't ensure monitoring protocols existed.
Meanwhile, the compression stocking grew tighter around the resident's leg as tissue swelled and circulation became compromised. The resident's refusal to allow removal should have triggered immediate physician consultation and alternative care strategies.
Instead, the situation festered for weeks while staff made assumptions and avoided direct responsibility for resolving the care barrier. The resident paid the price with severe tissue damage that required surgical repair and created risk of permanent limb loss.
Federal investigators found the facility violated regulations requiring proper assessment and monitoring of residents' conditions. The inspection was conducted in response to a complaint about the resident's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Mount Vernon from 2025-11-18 including all violations, facility responses, and corrective action plans.
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