F0684

E

Failure to Provide and Document ADL and Wound Care Treatments

Stockton, California Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to provide and document required ADL care for one resident with severe cognitive impairment and physical functioning deficits. The resident’s care plan, revised in September 2024, directed staff to provide assistance with ADLs, including hygiene, mobility, passive range of motion, and toileting, and to document the assistance provided. A complainant reported that staff were not providing care to this resident. On two separate observations on the same day, the resident was found in bed on her right side, wearing a hospital gown and covered with a blanket. Review of the resident’s Documentation Survey Report for a period in February 2026 showed no documented evidence that ordered ADL interventions such as turning and repositioning, bed mobility, passive range of motion to bilateral upper extremities, mouth care, personal hygiene (including hair and nail care, washing/drying face and hands), and toileting were provided on multiple day, evening, and night shifts. The Director of Staff Development confirmed that if care was not charted, it was considered not done and acknowledged that ADL care should have been recorded when provided.

The facility also failed to consistently provide and document ordered wound care treatments for a resident with a stage 3 pressure ulcer to the coccyx. This resident had a documented diagnosis of a sacral pressure ulcer, stage 3, and a treatment order on the Treatment Administration Record directing cleansing with normal saline, drying, application of Medihoney gel, and covering with a dry dressing three times weekly and as needed. An anonymous complaint alleged the facility was unsafe, and a nurse interview indicated that skin treatments, including pressure ulcer care, were not consistently provided. During an observation in the resident’s room, the stage 3 coccyx ulcer was found without a dressing in place, despite an order for a treated and covered wound. Review of the Treatment Administration Record for the month showed missing nurse initials on several ordered treatment days, and the DON confirmed that the absence of initials meant the treatments were not performed.

In addition, the facility did not ensure that ordered daily wound treatments were provided and documented for another resident with multiple advanced pressure ulcers. This resident had diagnoses including a stage 4 pressure ulcer to the left hip, a stage 4 pressure ulcer at another site (left scapula/shoulder), and an unstageable pressure ulcer to the left hip/trochanter. Treatment orders on the Treatment Administration Record required daily cleansing with normal saline, drying, application of silver alginate to the stage 4 wounds, and Silvadene with dry dressing to the unstageable necrotic wound, all to be covered with dry dressings each day shift. During an observation in the resident’s room, the stage 4 ulcers on the left shoulder and left hip and the unstageable ulcer on the left trochanter were found without dressings. Review of the Treatment Administration Record showed no nurse initials for one of the ordered treatment days, and the DON confirmed that the missing initials indicated the treatments were not done. Facility wound care procedures and nurse job descriptions required that wound care be provided as ordered and documented with date and time in the medical record, but this was not carried out for this resident on the identified date.

Facility policies on ADLs and wound care stated that residents unable to perform ADLs independently would receive necessary services for hygiene, mobility, and toileting, and that wound care would be provided and documented, including marking dressings with initials, time, and date and recording the date and time of wound care in the medical record. Job descriptions for RNs and LPNs/LVNs required monitoring skin health, providing preventive skin care, administering wound treatments as ordered, and maintaining documentation of all nursing care and services. Despite these written expectations, the survey findings showed multiple instances where required ADL care and wound treatments were either not documented or not in place at the time of observation, leading surveyors and facility leadership to conclude that the care had not been provided on those occasions.