WEST SAINT PAUL, MN - Federal inspectors at Southview Acres Healthcare Center documented multiple serious violations involving inadequate wound care monitoring, improper antibiotic management, and infection control failures during a January 2025 inspection.
Pressure Wound Care Monitoring Failures
The most significant violation involved inadequate monitoring and treatment of pressure wounds affecting two residents. Inspectors found that staff failed to follow proper protocols when new pressure injuries developed, potentially putting residents at risk for serious complications.
One resident developed new pressure areas on both buttocks after a previous wound had healed in December 2024. Despite having a care plan that required repositioning every two hours and using pressure-reducing equipment, the facility failed to implement adequate prevention measures. The resident was noted to frequently refuse repositioning and spent most days sitting in a recliner chair.
When nursing staff first observed the new wounds on January 5th, proper notification and assessment protocols were not followed. The physician's assistant was not notified about the new pressure areas, and no incident report was filed as required by facility policy. A nurse manager acknowledged missing required components in the resident's skin care plan, stating "I missed it" when asked about the lack of turning and repositioning schedules.
According to the inspection report, the physician's assistant stated that immediate notification is critical because "when a pressure area is not addressed right away the ulcers can increase in size, cause pain, also pressure areas are an avenue for infections."
The facility's wound care specialist confirmed that delayed action after identifying new skin impairment represents a significant risk, noting that "if a pressure area goes unchecked, it will get worse."
Medical Context: Why Pressure Wound Prevention Matters
Pressure ulcers develop when sustained pressure cuts off blood flow to skin and underlying tissue. For nursing home residents who have limited mobility, diabetes, poor circulation, or nutritional deficiencies, these wounds can quickly progress from minor skin irritation to deep, infected ulcers that may require surgical intervention.
Proper prevention requires frequent repositioning, appropriate support surfaces, good nutrition, and vigilant skin monitoring. When prevention fails and new wounds develop, immediate assessment and treatment are essential to prevent progression to more serious stages that can become life-threatening.
The nutritional factors identified in this case - including low albumin and hemoglobin levels - can significantly impair wound healing. Albumin is crucial for tissue repair and maintaining proper fluid balance, while adequate hemoglobin ensures sufficient oxygen delivery to healing tissues.
Antibiotic Stewardship Violation
Inspectors also identified a serious medication safety issue involving prolonged antibiotic use without proper monitoring. One resident continued receiving cephalexin, a broad-spectrum antibiotic, for over a month after hip surgery without an established end date.
The resident had been prescribed the antibiotic following hospital discharge in December 2024 for surgical site infection prevention. However, the hospital's discharge orders lacked a clear discontinuation date, and facility staff failed to establish appropriate monitoring protocols.
During the inspection, the resident told investigators: "I didn't think she had an infection and thought the antibiotic should have been stopped previously but staff kept bringing it to her, so she kept taking it."
The facility's infection control specialist discovered that the orthopedic provider had intended the antibiotic course to last only 18 days. When contacted during the inspection, the provider immediately ordered discontinuation of the medication.
Risks of Prolonged Antibiotic Use
Extended antibiotic therapy without clinical justification poses significant health risks. Unnecessary antibiotic exposure can disrupt the body's normal bacterial flora, leading to secondary infections such as Clostridioides difficile colitis, which causes severe diarrhea and can be life-threatening in elderly populations.
Prolonged antibiotic use also contributes to the development of antibiotic-resistant bacteria, making future infections more difficult to treat. The inspection found that this resident was receiving a higher-than-typical prophylactic dose, increasing these risks.
Proper antibiotic stewardship requires clear indication for use, appropriate dosing, and defined treatment duration with regular reassessment of continued need.
Laboratory Testing Delays
The facility also failed to ensure timely completion of diagnostic testing for another resident with suspected C. difficile infection. The resident experienced persistent diarrhea for approximately one month, but laboratory testing was delayed due to improper specimen collection and inadequate follow-up procedures.
An initial test ordered on December 16th was not properly followed up when results were not received. A second test was ordered two weeks later, but results were still delayed. The resident ultimately tested positive for C. difficile on January 5th and began treatment the following day.
The resident reported to inspectors: "I was unable to control her bowel movements because of the frequency and urgency of her bowel movements."
Additional Issues Identified
Inspectors documented several other violations affecting resident safety:
Infection Control Deficiencies: Staff failed to maintain proper cleaning standards for a resident's bed rails that were covered with deteriorating foam padding. The damaged covering could not be adequately disinfected, creating infection risks for a resident on enhanced barrier precautions.
Dietary Safety Violations: A resident with swallowing difficulties received unthickened liquids despite orders requiring nectar-thick consistency. The resident was observed coughing after drinking thin orange juice, indicating potential aspiration risk.
Inadequate Incontinence Management: Two residents did not receive appropriate toileting programs despite being cognitively intact and expressing preferences to use the toilet rather than incontinence products.
Equipment Protocol Failures: One resident requiring protective positioning devices was repeatedly observed without the ordered cushioning between knees, increasing pressure injury risk.
The inspection findings highlight systemic issues with care coordination, staff communication, and adherence to established protocols at the 120-bed facility. All violations were classified as causing minimal harm or potential for actual harm, indicating that while serious policy failures occurred, residents did not experience severe immediate consequences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southview Acres Healthcare Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
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