F0686

D

Failure to Perform Required Weekly Skin Assessments for Resident With Pressure Ulcers

Canton, Ohio Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete routine and comprehensive skin assessments for a resident with existing pressure ulcers and other skin impairments, as required by facility policy. On admission, the resident’s nursing assessment documented pressure ulcers on the bottom of the left foot and right outer heel, but did not include measurements or detailed descriptions of these ulcers. The resident was later discharged for planned spinal surgery and then readmitted, at which time the admission assessment noted an abrasion on the left buttock with measurements, a scab on the left heel with measurements, and a surgical incision on the back of the neck without measurements or description. There was no assessment of any pressure ulcer at readmission, and no subsequent skin assessments or documentation of wound healing were found in the medical record, despite a posted notice indicating the resident had a wound clinic appointment.

Wound clinic notes obtained by the facility showed that the resident had a stage 3 pressure ulcer on the sacrum and a stage 3 pressure ulcer on the right plantar foot. The DON confirmed that, aside from the limited admission assessments, the facility had no comprehensive assessments or documentation of healing for any of the resident’s skin impairments. Corporate nursing staff stated that the facility had a single wounds/skin impairments policy, which required a licensed nurse to complete a skin observation tool at least every seven days detailing any wounds or skin impairments. Corporate Nurse #503 verified that the resident’s non-pressure-related skin impairment was not assessed weekly by either the facility or the wound clinic, demonstrating noncompliance with the facility’s own wound/skin assessment policy.