Resident 40 arrived at the facility with a stage IV pressure ulcer on the sacrum that measured 4 centimeters by 6 centimeters. The wound was so deep inspectors classified it as "undetermined depth." Stage IV ulcers represent the most severe category, extending through skin and fat to underlying muscle and potentially bone.
The 82-year-old resident had moderate cognitive impairment and required substantial help with basic activities. She needed total assistance with bathing and toilet hygiene, and her care plan identified her as high risk for additional skin breakdown.
On September 22, physicians ordered cleaning the sacral wound with wound wash, patting it dry, and covering it with foam border dressing every three days. Three days later, that order was discontinued.
But the replacement order didn't come until September 23, when Wound Physician 1500 examined the ulcer and found it had grown to 5.5 centimeters by 7 centimeters by 1 centimeter deep. The physician ordered Mesalt with gauze dressing daily.
For two days, from September 23 through September 25, Resident 40 had two conflicting active orders for the same wound. The Director of Nursing confirmed this overlap during interviews with federal inspectors on December 23.
A second resident faced similar treatment gaps. Resident 50, who had been at the facility since May 2022, developed two stage III pressure ulcers despite being cognitively intact and able to communicate her needs.
The resident had systolic heart failure, chronic kidney disease, and a history of stroke. She required total assistance with bathing, toilet hygiene, bed mobility, and transfers. Her risk assessment classified her as high risk for skin breakdown.
By December, she had developed a stage III pressure ulcer on her sacrum measuring 4.5 centimeters by 0.6 centimeters, and another on her right ischium measuring 1 centimeter by 1.7 centimeters. Both wounds extended into the fat layer beneath the skin.
On December 2, Wound Physician 1500 examined both ulcers and recommended hydrocolloid paste treatments twice daily. The facility's care plan, revised that same day, specified wound treatments per physician orders.
Yet no formal treatment order existed until December 4, leaving a two-day gap. During this period, Resident 50 had stage III pressure ulcers but no active physician orders directing their care.
The Director of Nursing acknowledged both treatment gaps during the federal inspection.
Pressure ulcers develop when prolonged pressure reduces blood flow to skin and underlying tissue. Stage III ulcers extend through the full thickness of skin into fat tissue. Stage IV ulcers, like Resident 40's, extend deeper into muscle and can reach bone.
Both residents required complex wound care protocols. Stage IV ulcers like Resident 40's can take months to heal and carry risks of infection that can become life-threatening. The facility's own policy mandated evidence-based treatments according to current standards of practice for all residents with pressure injuries.
The gaps occurred despite both residents being identified as high risk for skin problems. Resident 40's assessment specifically noted she was admitted with an existing pressure ulcer, requiring immediate attention to prevent deterioration.
Federal inspectors found the treatment lapses during a complaint investigation that examined two separate concerns about the facility's wound care practices.
The facility's pressure injury prevention policy required continuous, appropriate treatment for all residents with existing wounds. The policy emphasized evidence-based care according to current medical standards.
Stage III and IV pressure ulcers require daily monitoring and specialized treatments to prevent infection and promote healing. Without active physician orders, nursing staff lack clear direction for wound cleaning, dressing changes, and medication application.
Resident 40's ulcer actually grew during her early days at the facility, expanding from 4 by 6 centimeters on admission to 5.5 by 7 centimeters when properly reassessed. The measurement change occurred during the period when treatment orders overlapped.
Both residents remained dependent on staff for positioning and personal care that directly affects pressure ulcer healing. Resident 50 required total assistance with transfers and bed mobility, activities that can worsen existing wounds without proper technique and scheduling.
The inspection classified the violations as causing minimal harm with potential for actual harm, affecting few residents. Federal regulators investigated the deficiencies under two separate complaint numbers, suggesting multiple concerns about the facility's wound care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Sanctuary At Tuttle Crossing from 2025-12-23 including all violations, facility responses, and corrective action plans.
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