The resident, identified as Resident #13, had intact mental capacity and suffered from paraplegia with a severe sacral pressure ulcer involving full thickness skin and tissue loss. Wound clinic orders from December 18, 2025, specified a detailed treatment protocol designed to promote healing and prevent infection.
On January 28, 2026, inspectors watched Staff G, a registered nurse, perform the wound treatment at 2:25 PM. The nurse looked at the computer orders, performed hand hygiene, and applied gloves. She opened gauze packaging and placed half the gauze on supplies without using a sterile barrier underneath.
Staff G then touched the computer with her gloved hands to reread the orders before taking acetic acid to dampen gauze. The orders required leaving the acetic acid-dampened gauze on the wound for 10 to 15 minutes to allow proper treatment. Staff G cleansed the wound but immediately removed the gauze, ignoring the time requirement.
The nurse then rolled the resident onto her back without placing any protective barrier underneath, leaving the cleansed wound area completely uncovered while she applied pain cream to the resident's right shoulder. The wound remained exposed and unprotected for 10 minutes.
At 2:35 PM, Staff G performed hand hygiene and repositioned the resident on her right side. She looked at the computer again to read the sacral area orders and applied new gloves, but failed to perform hand hygiene after touching the computer.
The contamination sequence began when Staff G used her gloved finger to extract Calmoseptine cream directly from the tube. She applied the cream to the first wound with that finger, then used the same contaminated finger to take more cream from the tube and treat a second wound.
Without changing gloves or performing hand hygiene, Staff G used the same contaminated hand to handle Melgisorb Ag calcium alginate dressing. She cut the dressing to size and placed it on the wound base with hands that had touched multiple wound sites and the cream tube.
Only then did Staff G remove her gloves and apply new ones, but she skipped hand hygiene between glove changes. She placed an ABD pad over the wounds, secured it with tape, and rolled the resident onto her back before removing gloves and signing off on the computer that treatments were completed.
The Director of Nursing acknowledged the treatment violations when interviewed by inspectors on January 29, 2026, at 10:05 AM. The DON explained that nurses were expected to follow wound care orders correctly and admitted the treatment was not completed according to the physician's specifications.
Stage 4 pressure ulcers represent the most severe category of pressure injuries, involving full thickness tissue loss that can extend into muscle and bone. Proper infection control during treatment is critical because these wounds create direct pathways for bacteria to enter deeper tissues and potentially cause life-threatening infections.
The facility reported a census of 26 residents at the time of inspection. Inspectors reviewed three residents for pressure ulcer care and found treatment failures affecting one resident.
The inspection was conducted in response to a complaint. Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing, with violations classified under tag F 0686.
Resident #13's MDS assessment showed a Brief Interview for Mental Status score of 15 out of 15, indicating completely intact cognition. The resident was fully aware of receiving substandard wound care that violated basic infection control principles and failed to follow the prescribed treatment timeline designed to promote healing of her severe pressure ulcer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Cresco from 2026-01-29 including all violations, facility responses, and corrective action plans.