The wound began as moisture-associated skin damage on the resident's left buttocks. By September 29, it had opened and expanded dramatically, but staff failed to create the required change-of-condition report that would have alerted physicians and the resident's representative.
Treatment Nurse 1 discovered the wound had increased to 6 centimeters in length and 4 centimeters in width during his assessment. The depth could not be determined. He told inspectors this represented a significant change of condition requiring immediate documentation and physician notification.
But no change-of-condition report was filed.
"I did notify the RN Supervisor that day but cannot recall who it was," Treatment Nurse 1 told inspectors on December 1. "I did not notify the MD and or the RP of Resident 3's change of condition."
When inspectors asked about an existing change-of-condition report dated September 29, Treatment Nurse 1 confirmed it was not related to the wound size increase. He stated there was "no way to determine if the RP and or MD was notified" of the resident's deteriorating condition.
The resident had been receiving daily wound care. Staff cleansed the area with normal saline, applied dermaseptine skin protectant ointment, and covered it with foam dressing. For the pressure injury portion, they used medical-grade honey dressing under foam coverage.
Despite this treatment protocol, the wound progressed from manageable skin damage to an unstageable pressure injury without proper medical oversight.
Director of Nursing confirmed the facility's failure during her December 1 interview with inspectors. She explained that change-of-condition reports are mandatory "when there is a new wound or if it has increased in size or there is a need for different staging."
She reviewed the resident's wound monitoring assessment and stated the facility "should have had a COC on 9/29/2025 for the wound size increase." Each significant change requires its own documentation, she confirmed.
The consequences extend beyond paperwork. "Not having a COC for the increase in Resident 3's wound size means not be able to monitor, potentially not able to treat the wound, and cannot say RP and MD were made aware," the Director of Nursing told inspectors.
Without physician notification, treatment plans cannot be adjusted appropriately. "If the MD is not notified it can also affect the treatment plan and delay in care," she acknowledged.
Federal regulations require nursing homes to inform residents, physicians, and resident representatives of significant changes in physical condition. The facility's own policy, last reviewed October 23, 2025, mandates notification of "significant change in the resident's physical, mental, or psychosocial status."
An unstageable pressure wound represents one of the most serious skin breakdown classifications. Unlike staged pressure injuries that can be measured for depth, unstageable wounds involve tissue death or damage that obscures the true extent of injury.
The progression from moisture-associated skin damage to an unstageable pressure wound typically indicates inadequate prevention measures or delayed intervention. Moisture-associated skin damage results from prolonged exposure to urine, feces, or wound drainage. When properly managed, it should resolve without advancing to pressure injury.
Treatment Nurse 1's inability to recall which supervisor he notified highlights communication breakdowns within the facility's wound care program. The lack of documented physician notification suggests systemic failures in the change-of-condition reporting process.
The facility's wound monitoring system appeared functional, with weekly assessments documenting size, depth, and treatment protocols. However, the critical link between assessment findings and physician communication broke down when the wound deteriorated significantly.
Federal inspectors classified this as a minimal harm violation affecting few residents. However, for the individual resident involved, the consequences were substantial. The wound required ongoing medical-grade honey treatments and daily foam dressing changes for at least 14 days.
The inspection occurred following a complaint, suggesting concerns about wound care quality reached outside observers. Desert Canyon Post Acute must now demonstrate corrective measures to prevent similar notification failures.
The resident continues receiving daily wound care, but the delayed physician notification may have prolonged healing time and complicated treatment options. Unstageable pressure wounds often require specialized interventions that primary care physicians must order promptly when conditions change.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Desert Canyon Post Acute, LLC from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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