Resident #135 developed a Stage II pressure ulcer on her right buttock and moisture associated skin dermatitis on her left buttock on November 9. But the facility's care plans, wound assessments, and consulting nurse practitioner's notes all mixed up the locations.
The resident had two separate care plans addressing her skin problems. One documented a Stage II pressure ulcer and moisture dermatitis to her left buttock. The other identified moisture dermatitis to the right buttock and a Stage II pressure ulcer to the left buttock.
Both were wrong.
A Stage II pressure ulcer involves partial thickness skin loss where the outer layer and part of the layer beneath are damaged, appearing as a shallow open sore with a red or pink wound bed. The facility's care plan called for staff to help turn and reposition the resident as needed, keep her from wearing depends while in bed, and cleanse both buttocks with soap and water every shift.
The wound nurse practitioner who consulted on the case examined Resident #135 on November 12. Her notes also incorrectly placed the pressure ulcer on the left buttock and the moisture dermatitis on the right.
Nobody caught the error until December 30, when the facility's Director of Nursing obtained a correction from the wound nurse practitioner after realizing the medical record contained conflicting information.
The addendum clarified that the pressure ulcer was on the resident's right buttock and the moisture dermatitis was on the left. But by then, Resident #135 had been discharged for nearly six weeks.
Other documentation problems compounded the confusion. A skin assessment grid indicated the pressure ulcer was present when the resident was admitted, even though it wasn't noted until November 9. The same assessment listed November 2 as the original date of the pressure ulcer, again contradicting when it was actually first documented.
LPN #229, the facility's certified wound nurse, confirmed the errors during a December 30 interview with inspectors. She was familiar with Resident #135's case and acknowledged the resident developed the Stage II pressure ulcer to her right buttock and moisture dermatitis to the left buttock on November 9.
She confirmed the care plans and wound nurse practitioner's notes had the locations reversed. She also verified the wound assessments incorrectly stated the pressure ulcer was present on admission and gave the wrong origination date.
"They have been having issues with the floor nurses entering the proper information on the wound assessments when it was first entered into the computer," LPN #229 told inspectors.
The wound nurse acknowledged the resident's medical record should accurately reflect the status of wounds, their location, and when they originated.
Resident #135 could not explain what happened due to cognitive decline. An interdisciplinary team met on November 10 to address her skin problems, agreeing to assist with turning and repositioning as needed and updating her care plan.
But the updated care plans still contained the contradictory information about which buttock had which condition.
The resident was discharged on November 18, nearly two weeks after developing the pressure ulcer. The mixed-up medical records remained uncorrected until inspectors arrived in response to a complaint more than a month later.
The documentation errors meant staff caring for the resident had conflicting instructions about which area needed specific wound care and which had the more serious pressure ulcer requiring different treatment protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Luxe Rehabilitation and Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.