KANSAS CITY, MO - Federal health inspectors found New Mark Rehab and Healthcare Center failed to provide adequate pressure ulcer prevention and treatment during a complaint investigation completed on November 21, 2025. The facility was cited for three deficiencies during the investigation, including a violation of regulatory tag F0686 related to pressure ulcer care.
Pressure Ulcer Prevention Breakdown
Inspectors determined that New Mark Rehab and Healthcare Center did not meet federal standards for providing appropriate pressure ulcer care or preventing new pressure ulcers from developing among its residents. The deficiency was classified at Scope/Severity Level D, indicating an isolated incident where no actual harm was documented but where the potential existed for more than minimal harm.
Pressure ulcers, commonly known as bedsores, develop when sustained pressure on the skin reduces blood flow to affected areas. They most frequently occur on bony prominences such as the heels, tailbone, hips, and shoulder blades. Residents who are immobile, use wheelchairs, or are confined to beds face the greatest risk. When a facility fails to implement proper prevention protocols, these wounds can progress rapidly from mild skin reddening to deep tissue injuries exposing muscle and bone.
Why Pressure Ulcer Prevention Is a Core Standard of Care
Federal regulations require nursing homes to ensure that residents who enter a facility without pressure ulcers do not develop them unless clinically unavoidable, and that residents who arrive with existing pressure ulcers receive treatment and services to promote healing and prevent infection. This standard exists because pressure ulcers are largely preventable with appropriate nursing interventions.
Proper prevention protocols include regular repositioning schedules — typically every two hours for bed-bound residents — along with adequate nutrition and hydration support, proper skin assessments upon admission and at regular intervals, moisture management, and the use of pressure-relieving devices such as specialized mattresses and cushions. When these protocols break down, residents face increased risk of developing wounds that can lead to serious complications.
Untreated or improperly managed pressure ulcers can result in significant medical consequences. Open wounds create pathways for bacterial infection, which can progress to cellulitis, osteomyelitis (bone infection), or sepsis — a life-threatening systemic infection. Advanced pressure ulcers also cause significant pain and can substantially reduce a resident's quality of life and functional ability.
Complaint-Driven Investigation
The citation resulted from a complaint investigation rather than a routine annual survey, meaning that concerns about care at the facility were reported to state or federal authorities, prompting the on-site inspection. Complaint investigations are targeted reviews that focus on specific allegations of substandard care.
The fact that inspectors substantiated the complaint and issued a formal citation indicates that the reported concerns were validated through their findings. The investigation identified this as an isolated deficiency rather than a facility-wide pattern, suggesting the failure may have affected a limited number of residents rather than reflecting a systemic breakdown in care protocols.
Facility Response and Correction
New Mark Rehab and Healthcare Center reported correcting the deficiency by November 22, 2025 — just one day after the inspection concluded. While the rapid correction timeline suggests the facility took prompt action to address the identified gaps, the speed of the reported fix also raises questions about why appropriate measures were not already in place.
The facility's correction status is listed as "Deficient, Provider has date of correction," meaning the facility has acknowledged the deficiency and submitted a plan to regulators. Federal guidelines require facilities to implement sustained corrective measures, not just immediate fixes, to prevent recurrence.
Industry Context
Pressure ulcer prevention remains one of the most frequently cited deficiency areas in nursing home inspections nationwide. According to federal data, thousands of nursing homes receive citations related to pressure ulcer care each year. The prevalence of these citations underscores ongoing challenges in the long-term care industry around staffing levels, staff training, and consistent implementation of prevention protocols.
Families of residents at New Mark Rehab and Healthcare Center may wish to review the full inspection report, which is available through Medicare's Care Compare website, for complete details on all three deficiencies cited during the November 2025 investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Mark Rehab and Healthcare Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
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