A resident identified as at risk for skin breakdown was evaluated by a wound NP, who recommended preventive interventions including floating the heels while in bed. This recommendation was not entered as a physician order and was not added to the resident’s care plan, despite the risk status. Later documentation showed the resident had developed multiple wounds, including heel/foot pressure injuries and a Stage 2 sacral pressure ulcer. Although the TAR reflected that weekly skin assessments were completed over several weeks, the skin observation tool in the EHR contained only a single documented assessment. The ADON and DON confirmed the lack of documentation for the weekly assessments and the failure to implement the heel-floating recommendation, and an LPN verified that only one weekly skin assessment was recorded and expressed uncertainty about who was responsible for entering new orders from wound care recommendations.
Surveyors found that the facility failed to timely obtain, transcribe, and implement wound care orders for two residents with in-house acquired pressure ulcers, and did not consistently assess or document these wounds. One resident developed a Stage 2 pressure ulcer on the posterior lower leg that was identified and measured by the skin team, but no wound care order was entered until nearly two weeks later, just before discharge. Another resident with hemiplegia had moisture-associated skin damage and a sacral wound for which a wound physician ordered specific treatment that was never transcribed to the order recap or TAR, and nursing documentation repeatedly conflicted with the physician’s Stage 3 pressure ulcer staging and measurements. For this second resident, wound treatment orders lapsed and changed over time without clear continuity, the emergency contact was not informed of the wound until much later, and the RD was never notified of the new pressure ulcer despite facility policy requiring IDT notification and coordinated wound treatment.
A resident with multiple comorbidities and an existing pressure area was admitted with a Braden score indicating mild risk, but facility staff documented the sacral moisture-associated skin damage without measurements or detailed wound characteristics and care planned the area to be left open to air. Subsequent Braden assessments continued to rate the resident as low risk, and care plans did not include specific q2h turning/repositioning, while CNA documentation showed numerous shifts where the resident was not turned. Later, two new pressure wounds on the coccyx and sacrum were documented without measurements or physician notification, and a wound consultant subsequently identified an unstageable full-thickness sacral pressure injury and a Stage 3 buttock wound, both present for more than five days, with no prior documentation of skin changes by the medical providers, indicating a failure to implement and communicate appropriate pressure ulcer prevention and management.
A resident admitted with multiple pre-existing PUs on the heels and coccyx did not receive pressure ulcer care consistent with professional standards. The wound NP documented specific treatment recommendations for each ulcer and later recommended an alternating air/low air loss mattress, but these orders were not promptly entered into the medical record, resulting in delayed and incomplete implementation. For days after admission, no coccyx PU treatments were documented, a left heel treatment order was entered late, and when a new left heel order was added, the old order was not discontinued, leading to both treatments being charted on multiple days. The NP later documented that the right heel PU had progressed to a DTI and that the coccyx ulcer had significantly increased in size. The admission MDS did not capture all existing PUs, and the resident lacked a comprehensive care plan with measurable goals for PU management. Staff interviews confirmed that the process for transcribing NP orders and initiating care plans broke down, contributing to these deficiencies.
A resident admitted with talar osteomyelitis of the left foot had additional wounds documented by the admitting nurse, including a scab on the left ankle, a sore on the left foot, and a sore on the left heel, but no wound treatment orders were obtained at admission. The attending physician repeated the hospital osteomyelitis note, documented no skin lesions, did not address the additional wounds, and did not initiate wound care, stating later that a wound specialist handles such care. The wound NP did not assess the resident until 10 days after admission, at which time a venous ulcer on the left medial malleolus, a left plantar diabetic foot ulcer, and an unstageable pressure ulcer on the left heel were identified and treatment started. The DON reported that the admitting LPN should have clarified the discharge instructions and notified the physician for orders for all identified wounds.
A resident at risk for skin impairment had a LAL mattress ordered with instructions to check functionality and weight settings every shift. The mattress control unit was observed set at 180 soft even though the resident’s documented weight was 110.4 pounds, and both an RN and an LPN documented the settings were correct despite the mismatch with the manufacturer’s manual.
Inadequate monitoring and documentation of a Stage IV sacral pressure injury. A resident with immobility and comorbidities had an ongoing sacral wound treated with hypochlorous acid solution, but wound documentation did not show evaluation of treatment effectiveness or complete wound characteristics. The record also showed a 14-day gap without a documented wound assessment, even though the wound had been described as worsening on a prior observation tool.
Inaccurate pressure-relieving mattress settings were found for three residents with pressure injuries. Each resident had an order for the mattress to be set within 10 lbs of current weight, but the observed settings were far above the documented weights. Staff gave differing responses about who was responsible for setting and checking the equipment, and the wound nurse confirmed the settings were not accurate.
The facility failed to timely implement and update wound care orders and consult recommendations for multiple residents with pressure and arterial ulcers. In one case, a resident’s new sacral skin impairment was noted without adequate description, and a wound consult ordered by the physician was not completed for nine days, at which point a Stage 3 coccyx wound was documented. For another resident, a sacral wound was identified and physician treatment instructions were obtained, but the corresponding wound care order was not entered and implemented until three days later. A third resident with a left dorsal foot arterial ulcer had an existing every-other-day NSS-based treatment order that was not revised after a wound consult recommended a different, daily wound care regimen and continuous offloading in a Prevalon boot while in bed. The DON acknowledged that wound consults and related orders are expected to be implemented immediately or by the next day.
A resident with adult FTT developed a new skin condition on the buttock that was later assessed by a wound physician as a Stage III pressure ulcer, with an order for daily Calcium Alginate dressing. Review of documentation showed staff continued using wound cleanser and did not implement the ordered Calcium Alginate treatment for several days until the order was changed to zinc ointment every shift. The Regional Director of Clinical Operations confirmed that the ordered pressure ulcer treatment was not provided as directed.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account