Failure to Update Care Plan for New Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident after the discovery of a new stage III pressure ulcer on the posterior of the left foot. Record review showed that the resident's care plan had last been revised for skin alteration on 6/9/25, but there was no evidence that it was updated to address the new pressure ulcer and the associated skin care needs. During an interview, the Assistant Director of Nursing confirmed that the care plan did not reflect the resident's current wound status or the care required for treatment. This deficiency was identified through clinical record review and staff interview, focusing on the lack of timely care plan updates following a significant change in the resident's condition.