The Center for Nursing and Rehab at Hoosick Falls failed to follow through on hospital wound care orders from August 4, 2025, leaving Resident #1 without proper treatment until at least August 21, when inspectors discovered the oversight during a complaint investigation.
Hospital wound specialists had identified six wounds requiring treatment during the August 4 consultation. But when inspectors reviewed the facility's medication administration records from August 1 through August 21, they found no documentation of wound treatment orders. Nursing progress notes from August 4 to August 21 contained no mention of the new back wound.
The resident's care plan, hastily revised on August 21 as inspectors conducted interviews, finally acknowledged "actual skin impairment" including pressure ulcers on the right heel and lateral foot, venous ulcers on the right lower extremity, coccyx, and back. The plan's interventions were generic: "report any skin changes to provider as necessary; wound care treatment(s) as ordered."
But there were no orders to follow.
Director of Nursing #1 admitted during an August 21 interview that "wound #6 was not identified by the facility and there was no order for the treatment." She explained that the resident had a wound on their spine that had closed in July 2025, then reopened.
The communication breakdown stemmed from the facility's haphazard system for receiving hospital consultation reports. Director of Nursing #1 said the hospital wound care note from August 4 wasn't faxed to the facility until August 19 — a fifteen-day delay that left the resident without documented care for the back wound.
"Sometimes the consult note was not dictated right away, and the facility would not receive the report until three or four days later," Director of Nursing #1 explained. She acknowledged that "best practice would be for the facility to call the wound care clinic when the resident returned without documentation."
They didn't call.
Assistant Director of Nursing #1 described the facility's reliance on paper documentation that residents or family members were supposed to carry back from appointments. "Resident #1 usually returned with documentation from the hospital wound care center that was either given to them or Director of Nursing #1," she said during an August 20 interview.
But the system regularly failed. Director of Nursing #1 admitted "there was a day when the resident came back from the wound consult and did not have paperwork."
The resident's case highlighted broader communication problems between the nursing home and outside specialists. Administrator #1 complained during an August 21 interview that "there was a delay in getting consult notes from the wound clinic" and that "the wound clinic would not call the facility when they identified a new wound."
This resident was particularly vulnerable. Director of Nursing #1 explained that Resident #1 had been sent to the hospital wound care center because "the resident was refusing wound care" from the facility's in-house wound care provider. The resident had spina bifida, a birth defect affecting the spine that can complicate wound healing and mobility.
Despite these challenges, nursing staff described a computer system that should have prevented the documentation gap. Licensed Practical Nurse #2 stated during an August 22 interview that "wound care orders were documented in the computer system" and that when residents returned from outside consultations, "they would have paperwork that was given to the Assistant Director of Nursing #1 or Director of Nursing #1."
Licensed Practical Nurse #3, working through an agency and only her second time in the building, understood the same protocol: residents returning from wound consultations "would return with paperwork and they would inform Director of Nursing #1 or the Assistant Director of Nursing #1."
The system worked in theory. In practice, Resident #1's back wound went untreated for weeks.
Director of Nursing #1 described the facility's process for entering orders once consultation notes finally arrived: "When consult notes were faxed, they were scanned into the computer system by the Medical Records staff person and then they would notify them that it was scanned. Director of Nursing #1 would then contact the physician and enter the order into the computer system."
But by the time the August 4 consultation note reached the facility on August 19, the resident had spent over two weeks without documented wound care for the back injury. Assistant Director of Nursing #1 acknowledged during her interview that hospital consultation notes identified "six wounds with treatments and there should be corresponding orders for all treatments in the computer system."
The facility's administration records from August 1 to August 20 contained no orders for the back wound. The medication administration record from August 1 to August 21 showed no wound treatments. Nursing progress notes from the same period made no mention of monitoring or assessing the newly identified back wound.
Administrator #1 characterized the situation as a communication failure, noting that Resident #1 was "the only resident in the facility who was sent out for wound care." But the isolation of this case made the oversight more troubling, not less — with only one resident receiving outside wound consultations, staff had fewer cases to track and more reason to ensure proper follow-through.
The resident with spina bifida, already struggling with wound refusal and a history of spinal injuries that opened and closed unpredictably, spent more than two weeks without the wound care that hospital specialists had deemed necessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Center For Nursing and Rehab At Hoosick Falls from 2025-11-26 including all violations, facility responses, and corrective action plans.