Resident 1 at Transitional Care of Seattle developed the injury on January 14, 2026. Staff didn't assess its measurements and characteristics until January 19.
The resident had refused 17 meals between December 29, 2025 and February 5, 2026. Staff documented one refused bath, five declined weekly weighings, and multiple medication refusals during the same period.
Nobody told the doctor.
Federal inspectors found no indication in progress notes that staff informed providers about any of the refusals or tried to determine why the resident was declining care.
Staff B told inspectors during a January 30 interview that Resident 1 "refused to get out of bed and refusing most intakes by mouth." When asked why, the staff member said it was "resident driven" and that staff "were having difficulties getting care done."
The facility's own investigation concluded the pressure injury resulted from "profound immobility, deconditioning from sepsis, malnutrition and inadequate hydration." Staff implemented frequent turning documentation and ordered Ensure three times daily as interventions.
But the assessment delay raised questions about wound care protocols. During a February 11 interview, Staff B acknowledged there should be weekly wound documentation including measurements and characteristics.
When inspectors asked why the new pressure injury wasn't assessed until five days after discovery, Staff B said they would "have to ask the wound nurse" and couldn't answer the question.
The facility's risk assessment system showed internal contradictions. Staff B told inspectors Resident 1 was at "extreme risk for wounds," but the documented Braden assessment indicated only "moderate risk."
When confronted about which assessment was accurate, Staff B maintained the resident was at extreme risk.
Resident 1 required complete staff assistance. "Resident 1 was dependent on staff for turning/repositioning in bed and for all transfers out of bed," Staff B confirmed to inspectors.
The inspection documented a pattern of care refusals without corresponding clinical intervention. Beyond the 17 refused meals, records showed the resident declined one bath and had one documented episode of refusing care during the review period.
Federal regulations require nursing homes to ensure residents maintain acceptable parameters of nutritional status and to provide wound care that promotes healing and prevents new wounds.
The delayed assessment occurred despite clear protocols. Staff B acknowledged weekly wound documentation requirements during the February interview but couldn't explain the five-day gap between discovery and assessment.
Inspectors found the violation resulted in minimal harm or potential for actual harm to a few residents. The finding triggered federal oversight requirements for the facility's wound care procedures.
The case illustrates challenges nursing homes face when residents consistently refuse care. But federal standards require facilities to investigate refusal patterns and involve medical providers in developing alternative approaches.
Staff documented Resident 1's care refusals meticulously. The medical record contained detailed entries about declined meals, missed baths, and avoided weighings. What was missing was any indication that anyone asked why or notified physicians about the pattern.
The resident's condition deteriorated despite staff awareness of extreme wound risk. Sepsis, malnutrition, and dehydration contributed to skin breakdown, according to the facility's root cause analysis.
Transitional Care of Seattle implemented nutrition supplements and turning documentation after the pressure injury developed. But the five-day assessment delay suggested gaps in wound surveillance protocols for high-risk residents.
The inspection occurred following a complaint filed with state health officials. Federal surveyors completed their review on January 30, 2026, documenting deficient practices under federal tag F686 for failure to provide necessary care and services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Transitional Care of Seattle from 2026-01-30 including all violations, facility responses, and corrective action plans.