Crittenden County Health & Rehab: Wound Care Failures - KY
The inspection, completed February 7, 2025, documented what federal surveyors found the afternoon before, when they watched the nurse, identified in the report as LPN1, perform wound care on a resident living with two chronic open areas, one on each buttock.
The wounds were serious enough to have their own entries in the resident's Comprehensive Care Plan, which had been in place since at least May 2023. The left buttock wound had been verified by a physician as a chronic fistula, a type of abnormal tunnel that forms in tissue and resists ordinary healing. The right buttock wound had its own care plan entry dating to May 2024. Both carried the same goal: heal the skin and prevent infection.
The physician's orders were specific. As of January 18, 2025, staff were to cleanse the wounds with Dial soap and water, then apply Neosporin ointment, a triple antibiotic, directly to the wounds. The orders had been in place for nearly three weeks by the time inspectors watched LPN1 work.
He did neither.
Instead of Dial soap and water, LPN1 used Dakin's solution, a chlorine-based wound irrigant with a different chemical profile and a different clinical purpose. Instead of Neosporin ointment, he applied Dermacil, a topical skin lotion. The inspection report does not indicate that LPN1 had any authorization to substitute either product.
The next day, when surveyors interviewed him, LPN1 did not dispute what they had seen. He confirmed he had not followed the care plan. He confirmed the care plan existed to tell every staff member how to care for each resident. He acknowledged he had not delivered the prescribed treatment.
Then he explained why.
He hadn't taken the time to put on a gown before providing care, which the care plan identified as an evidence-based practice for this resident. He knew he should have. He just didn't.
That explanation, offered without apparent hesitation, sat at the center of what inspectors cited under F0656, the federal tag covering comprehensive care plans and staff's obligation to follow them. The violation was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The gap between what a care plan requires and what a nurse actually does during a routine treatment is not always visible. Wound care happens behind closed doors, during busy shifts, without a supervisor watching. What the February 6 observation captured was a moment that, by LPN1's own account, was not unusual enough to prompt any explanation beyond time.
Chronic fistula wounds do not resolve on their own. They require consistent, prescribed treatment to prevent the kind of bacterial colonization that turns a manageable wound into a systemic infection. The physician who ordered Dial soap and water and Neosporin made a clinical judgment about what this resident's wounds needed. LPN1 substituted his own products without documented authorization and without apparent concern that doing so deviated from a physician's order.
The care plan had been in place for months. The treatment order had been active for nearly three weeks. Neither fact appeared to register as a reason to follow the written instructions.
Crittenden County Health & Rehabilitation Center is a skilled nursing facility at 201 Watson Street in Marion, a small city in western Kentucky. The inspection was conducted under standard federal health survey procedures by the Centers for Medicare and Medicaid Services.
The resident with the fistula wound and the open right buttock wound remains a patient at the facility. The inspection report does not describe what, if anything, changed about their wound care after surveyors left the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crittenden County Health & Rehabilitation Center from 2025-02-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
Crittenden County Health & Rehabilitation Center in Marion, KY was cited for violations during a health inspection on February 7, 2025.
The wounds were serious enough to have their own entries in the resident's Comprehensive Care Plan, which had been in place since at least May 2023.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.