Resident 17, an 83-year-old woman with Alzheimer's disease and severe cognitive impairment, had been receiving respite care at the facility since July. On December 4, a hospice shower aide approached the facility nurse to report bruising and swelling on the resident's lower left leg.
The aide noted two dark-colored bruises, but nursing staff recorded no measurements, descriptions, or exact locations of the skin alteration in the resident's medical record.
For the next 15 days, progress notes contained no specific information about where the bruising was located or any description of the bruise, including size or color changes. Weekly skin assessments conducted on November 25, December 2, December 9, and December 16 documented no skin issues at all, including no mention of bruising or skin injuries.
Shower logs from December 4 through December 19 revealed no skin assessments or documentation to support monitoring of the reported bruising on the resident's lower left leg.
Even hospice notes from the same period mentioned the bruising but contained no documentation or descriptors of the injury at any point during the resident's stay.
The resident had been admitted for palliative care with multiple conditions including Alzheimer's disease, dementia, amnesia, visual hallucinations, chronic fatigue, and heart valve problems. Her November 18 assessment confirmed severe cognitive impairment.
When federal inspectors interviewed facility leadership on December 23, the current Director of Nursing, a new Director of Nursing, the Administrator, and Assistant Director of Nursing confirmed they had no documentation to support that the bruising was monitored, measured, or described.
The leadership team acknowledged the bruise should have been monitored after identification. They told inspectors they would obtain hospice records to determine if hospice staff had monitored the injury.
The next day, the Director of Nursing confirmed that hospice records contained no descriptive language about the bruise on the resident's lower left leg either.
The facility's own skin assessment policy, dated 2022, requires a full body assessment as part of a systematic approach to pressure injury management. Licensed or registered nurses must conduct head-to-toe skin assessments upon admission, daily for three days, and weekly thereafter.
The policy also mandates assessments after any change in condition or newly identified pressure injury.
Despite these clear requirements, staff failed to follow protocol when the hospice aide reported the bruising. No measurements were taken. No descriptions were recorded. No monitoring occurred over more than two weeks.
The violation occurred at a 33-bed facility where staff are responsible for tracking and documenting all skin changes, particularly for vulnerable residents with cognitive impairments who cannot report injuries themselves.
Resident 17's severe dementia meant she relied entirely on staff to identify, document, and monitor any injuries or changes to her condition. The hospice aide who discovered the bruising worked for an outside agency, not facility staff.
The failure to document basic details about the bruising meant administrators had no way to determine whether the injury was healing, worsening, or changing in any way. Without measurements, photographs, or written descriptions, staff could not track the bruise's progression or determine if medical intervention was needed.
Federal regulations require nursing homes to provide appropriate treatment and care according to physician orders, resident preferences, and goals. The inspection found Brown Memorial Home failed to meet this standard.
The violation was investigated as part of complaint number 2691551 and affected one of three residents reviewed for skin alterations during the December 24 inspection. Inspectors classified the harm level as minimal or potential for actual harm.
Resident 17 remained at Brown Memorial Home throughout the period when her bruising went unmonitored, with no record of whether the injury ever healed or required medical attention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brown Memorial Home Inc from 2025-12-24 including all violations, facility responses, and corrective action plans.