The resident told staff her left leg pain and tailbone pressure sore prevented her from standing. Family members reported she was unable to stand due to a foot ulcer and the persistent tailbone wound.
Her original care plan for pressure sore risk was created in November 2024. When the tailbone wound reopened in April 2025, staff simply resumed the old interventions without making any changes.
"This wound was on and off," Nursing Supervisor 1 told inspectors on September 30. When asked if there were any updates to the treatment plan, the supervisor said no. "There were no updated interventions for this reported wound, but the old interventions were resumed."
The Director of Long Term Care and Quality Assurance confirmed that interventions were simply resumed from the November plan, with no additional revisions made for the pressure injury. The director agreed interventions should have been revised.
Staff created two separate care plans that addressed different aspects of the resident's skin problems. One plan focused on reducing risk factors to prevent future pressure sores. The other focused on healing existing wounds.
"The goals identified in the risk care plan focused on addressing risk factors with interventions to reduce risk of future ongoing pressure injuries, while the skin issue care plan and interventions focus on healing/treating the identified skin issues," the quality assurance director explained.
But the risk prevention plan was never updated. The director agreed that interventions should have been updated "at least with every new in-house pressure injury and more frequently throughout resident's stay."
The resident attended multiple care team meetings throughout her stay. Records show meetings on December 8, 2024, May 30, 2025, June 10, 2025, July 29, 2025, July 31, 2025, August 17, 2025, and August 19, 2025.
None of those meetings included discussions about updating treatment orders, reviewing the impact of current wound treatments, or working with the resident and family to develop new interventions to reduce her risk for continued skin breakdown.
The facility maintained the same interventions from November 2024 through at least August 2025, even as the resident's condition prevented her from basic activities like standing or sitting comfortably in her wheelchair.
Staff acknowledged they were using two different care planning systems that should have worked together but didn't communicate effectively. The risk reduction plan remained static while the resident developed new pressure sores that required active treatment.
The resident's mobility became increasingly limited as her condition worsened. Meeting notes documented that both family and the resident reported she was unable to stand due to multiple wounds and pain.
Federal inspectors found the facility failed to ensure the resident's care plan was comprehensive and updated as her condition changed. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The inspection occurred after a complaint was filed about the facility's care practices. Supervisors admitted during interviews that their approach to updating care plans was inadequate for residents with recurring skin problems.
The quality assurance director's acknowledgment that interventions should have been revised more frequently highlighted a systemic gap in the facility's care planning process. Staff recognized the problem but had not implemented solutions.
The case illustrates how administrative failures can compound medical problems. While the resident struggled with pain that limited her ability to stand or sit, the facility continued using months-old treatment approaches without reassessment.
The resident's experience spanned nearly a year, from November 2024 through the inspection in October 2025. Throughout that period, her care plan remained essentially unchanged despite recurring wounds and declining mobility.
Staff interviews revealed they understood the difference between preventing pressure sores and treating existing ones, but failed to coordinate these approaches effectively for residents with ongoing problems.
The facility's approach left the resident managing multiple painful conditions while staff followed outdated intervention strategies that weren't working to prevent new wounds or address her increasing limitations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jewish Home & Rehab Center D/p Snf from 2025-10-03 including all violations, facility responses, and corrective action plans.
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