The resident, identified as #164, entered the facility on an unspecified date in March. A skin check wasn't initiated until March 28 at 7:33 PM, but the nurse didn't sign off on it until March 31. That same day, a progress note documented as a "late entry" finally acknowledged what staff had found days earlier: pressure injuries to the sacrum and right heel, along with abrasions on both forearms.
The right heel injury measured 8.2 centimeters long, 3.3 centimeters wide, and 0.1 centimeters deep when finally assessed on March 31 at 12:42 PM. The wound was pink and red with discolored edges. Surrounding tissue was described as denuded, discolored black or blue, dry and flaky, and fragile.
No measurements were recorded for the sacral pressure injury during the March 31 evaluation. Both wounds were classified as deep tissue pressure injuries present on admission.
Treatment orders weren't written until March 31. For the heel injury, staff were instructed to cleanse with hydrating foam cleanser, pat dry, apply sure prep, and leave open to air during day and night shifts. The sacral wound required cleansing with hydrating foam cleanser and application of zinc oxide paste twice daily.
By April 7, the right heel pressure injury had shrunk significantly to 1.5 centimeters in length and 1.0 centimeters in width, suggesting the delayed treatment may not have caused permanent harm in this case.
The facility's own policy, titled "Skin Integrity and Wound Management" and revised as recently as September 15, clearly states that wound evaluation should be completed upon admission or readmission. The policy also requires identifying necessary treatment interventions.
During a September 29 interview, the Director of Nursing acknowledged the facility had failed its own standards. She admitted that Resident #164's deep tissue pressure injuries had not been fully assessed upon admission and that treatment had not been initiated when the resident arrived.
"It was the facility's standard of care to assess and initiate treatment for pressure ulcer injuries upon admission," the Director of Nursing told inspectors.
The three-day delay occurred despite multiple staff interactions with the resident. The initial skin check on March 28 clearly documented pressure injuries to both the sacrum and right heel. Yet no formal wound assessment was performed until March 31, and treatment orders weren't written until the same day.
Deep tissue pressure injuries represent serious wounds where tissue damage occurs beneath the skin surface. These injuries typically appear as purple or maroon discolored areas and can rapidly deteriorate without proper care. The resident's heel injury showed classic signs: discolored surrounding tissue that was fragile and compromised.
Federal inspectors classified this as a violation with minimal harm or potential for actual harm. The deficiency affected one resident out of eight reviewed in the pressure ulcer care area. Heritage Center's census at the time was 157 residents.
The inspection was conducted as a complaint investigation on September 30, 2025. The facility provided no additional information beyond the Director of Nursing's acknowledgment of the care failures.
Pressure ulcers remain one of the most serious quality indicators in nursing home care. Facilities are required not only to prevent new ulcers from developing but also to provide appropriate care for existing wounds. When residents arrive with pressure injuries, immediate assessment and treatment can mean the difference between healing and deterioration.
In this case, the resident's heel wound did eventually heal significantly, shrinking by more than 80 percent in length within a week of proper treatment beginning. But the three-day delay violated both federal standards and the facility's own written policies.
The violation highlights a gap between Heritage Center's written procedures and actual practice. While the facility's wound management policy clearly required immediate assessment upon admission, staff failed to follow those protocols when Resident #164 arrived with visible pressure injuries.
No follow-up enforcement actions were documented in the inspection report. The facility was required to submit a plan of correction addressing how it would ensure proper wound assessment and treatment upon admission going forward.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Center from 2025-09-30 including all violations, facility responses, and corrective action plans.