The facility's wound care nurse discovered the mother had been changing the dressing on several occasions when she arrived after 6 PM. Staff had to tell her verbally not to change the dressing and to notify nurses when it became soiled instead.
The resident's care plan from July 30, 2025 indicated an interdisciplinary team meeting was scheduled for 4:45 PM that day with the mother. No documentation exists that the meeting ever occurred.
"No care plans were documented or updated by the MDS nurse or the DON RN, regarding IDT meeting with mother consultation or interventions on care for Resident #4," inspectors wrote.
The pressure wound required daily dressing changes with specific medical protocols. Doctor's orders from October 11 called for cleaning the full-thickness stage 4 wound on the resident's right buttock with saline, packing it with gauze dampened in half-strength Dakin's solution, and covering it with a super absorbent adhesive dressing.
During interviews on October 15, the wound care nurse said she understood that after speaking with the doctor and social worker, an interdisciplinary meeting would be scheduled and care plans updated. But the social worker confirmed she only documented that the meeting was scheduled — no additional notes were added to progress notes or care plans.
The facility's assistant director of nursing, who had worked there only three to four weeks, said the hospice care plans for another resident should have been added to comprehensive care plans as well. Resident #3 was receiving hospice care with a skilled nurse once weekly and hospice aide care three times weekly, but none of this appeared in the facility's care planning documents.
"It is the responsibility of the DON RN to complete, update, and sign the admission base line care plans, and comprehensive care plans," the assistant director said she was told by the corporate nurse.
The director of nursing, hired as an interim replacement due to a recent transition, said the MDS nurse had been out sick. She told inspectors the team was addressing care plan issues in daily morning meetings.
But those meetings weren't producing documentation. The administrator confirmed that care plans failed to address hospice care for one resident or document the interdisciplinary meeting requested by the other resident's mother about wound dressing protocols.
The administrator said the director of nursing and MDS coordinator were responsible for ensuring assessments were accurate and that the facility followed Resident Assessment Instrument guidelines. She confirmed the policy required following federal assessment protocols.
The facility's own care planning policy from March 2022 required developing comprehensive care plans within seven days of completing MDS assessments and no more than 21 days after admission. The policy stated that care plans must include measurable objectives and timetables to meet residents' medical, nursing, mental and psychological needs.
Federal inspectors found the facility failed to develop comprehensive care plans that addressed the identified needs of multiple residents. The violation affected some residents with minimal harm or potential for actual harm.
The wound care nurse had told the mother that nursing staff would change the dressing daily and as needed. But without proper care plan documentation or the promised family meeting, the mother continued changing the medical dressing herself when she visited in the evenings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rose Trail Nursing and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
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