Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive, person-centered care plan for a resident who developed pressure ulcers after admission. The resident, admitted with a history of spinal fusion, protein calorie malnutrition, and iron deficiency anemia, was found to have developed two stage 2 pressure ulcers on the lower back, as documented by a wound consultant. Subsequent wound consultant notes indicated ongoing pressure injuries over several months. Despite these findings, the resident's care plan did not include individualized interventions or a plan of care addressing the actual skin breakdown and development of pressure ulcers. This omission was confirmed during an interview with the Director of Nurses, who acknowledged that a care plan for the pressure injuries was not in place until after the issue was identified by surveyors.