The resident told federal inspectors at The Merriman that his wound treatment had fallen off the previous night, but staff hadn't replaced it despite having direct contact with the area during diaper changes.
The 45-bed facility was cited for failing to ensure pressure ulcer treatments were completed as ordered during a November complaint investigation.
Resident #5 had been living at the facility since April 2024 with a stage IV pressure ulcer on his penis. Stage IV ulcers represent the most severe category of pressure wounds, with full-thickness tissue loss extending down to muscle, bone, or supporting structures like tendons and joints.
His physician had ordered a specific treatment protocol: cleanse the penis with soap and water, apply Skin Prep to form a protective barrier around the wound area, fill the ulcer with collagen, and cover with an abdominal pad at bedtime.
Nursing records showed staff had performed the treatment on November 11. But when inspectors observed wound care the next morning at 8:30, no dressing was in place.
The resident explained what had happened. During incontinence care the night before, his wound dressing had come off. Staff never replaced it.
Licensed Practical Nurse #522 confirmed to inspectors that no dressing was present on the wound.
The oversight was particularly concerning given the location of the injury. The wound dressing was positioned inside the resident's incontinence brief, exactly where staff would handle during routine diaper changes.
When inspectors interviewed the administrator about the missing treatment, they asked whether the resident had informed staff that the dressing had fallen off. But the administrator acknowledged the obvious problem with that expectation.
Staff would have seen the dressing wasn't intact during incontinence care, the administrator told inspectors. They should have noticed it had come off and alerted nursing staff that a new treatment was needed.
The facility's own undated policy on pressure injury treatment emphasized that wounds would be treated with consistent protocols to aid healing. But consistency had broken down in this case.
Multiple sclerosis patients face particular challenges with pressure ulcers due to reduced mobility and sensation. The resident's stage IV ulcer represented months or years of tissue breakdown that had reached the most severe classification possible.
Proper wound care for stage IV pressure ulcers requires meticulous attention to prevent infection and promote healing. The collagen filler ordered by the physician helps fill the deep wound cavity, while the protective barrier prevents further skin breakdown from moisture.
The inspection found the treatment failure during a complaint investigation at the facility. The Merriman houses 45 residents, and inspectors reviewed pressure ulcer care for three residents during their visit.
Only this resident experienced the treatment breakdown, but the case illustrated how gaps in basic nursing observation could compromise care for the facility's most vulnerable patients.
The resident had been without his prescribed wound treatment for an undetermined period when inspectors discovered the oversight. His penis wound remained exposed and unprotected, exactly the conditions that allow stage IV pressure ulcers to worsen or develop infections.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. But for a resident already dealing with multiple sclerosis and living with a severe genital wound, any interruption in prescribed care represented a failure of basic nursing responsibility.
The administrator's acknowledgment that staff should have noticed the missing dressing during routine care highlighted how the oversight occurred during the most fundamental nursing task - helping residents with incontinence.
This was precisely when trained nursing staff should recognize and respond to changes in a resident's condition or treatment needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Merriman from 2025-11-26 including all violations, facility responses, and corrective action plans.