EAGLE GROVE, IA - Federal inspectors cited Rotary Senior Living for failing to detect a dangerous antibiotic-resistant infection that developed under a resident's medical brace, only discovered when a dermatologist noticed suspicious drainage during an unrelated appointment.
Hidden Infection Escapes Detection
The February 2025 inspection revealed that staff failed to follow the facility's own care plan requiring skin inspections when applying and removing a resident's ankle-foot orthotic (AFO) brace. The resident's care plan specifically mandated that staff "inspect his skin before and after applying the AFO" and conduct weekly skin assessments.
During a routine dermatology appointment for an unrelated condition, the specialist noticed a darkened area under the brace's Velcro strap. When the dermatologist pressed on the wound, white drainage emerged from beneath a dark scab. Testing revealed the infection was caused by Methicillin-resistant Staphylococcus aureus (MRSA), a dangerous bacteria resistant to many common antibiotics.
The resident told investigators that staff routinely applied and removed his ankle brace twice daily but confirmed he had no knowledge of whether they checked his skin during the process.
Medical Equipment Creates Vulnerability
Ankle-foot orthotics are prescribed to help patients with mobility issues maintain proper foot positioning and prevent complications from conditions like stroke-related weakness. However, these devices can create pressure points and trap moisture against the skin, making regular skin inspection essential for preventing complications.
MRSA infections are particularly concerning in healthcare settings because they resist treatment with methicillin and related antibiotics. These infections can spread through contact and may cause serious complications including bloodstream infections, pneumonia, and surgical site infections.
The missed infection required aggressive antibiotic treatment. Initial therapy with cephalexin was discontinued when culture results confirmed MRSA, and treatment was switched to doxycycline, an antibiotic effective against resistant bacteria.
Documentation Failures Compound Problem
The facility's records showed no documentation of skin assessments related to the brace removal and application, despite clear care plan requirements. A certified nursing assistant's shower report from February 4 - just two days before the infection was discovered - left the skin assessment section blank, with no indication that "no skin concerns" were noted as required by facility procedures.
Multiple staff members confirmed to investigators that skin checks were not being documented or consistently performed. The facility's own weekly skin assessment policy required comprehensive skin inspections focusing on high-risk areas, with documentation of any concerns, redness, or open areas.
Professional Standards Compromised
Standard medical practice requires careful monitoring of skin under orthotic devices, particularly for patients with conditions that may impair sensation or circulation. The resident had a history of stroke resulting in weakness on one side of his body, making him particularly vulnerable to unnoticed skin breakdown.
The facility's care plan recognized this vulnerability by specifically requiring skin inspection before and after brace application. However, the complete lack of documentation and staff confirmations indicate these essential safety measures were not being followed.
Additional Staffing Concerns
The inspection also revealed issues with staff conduct and reporting procedures. In a separate incident, facility staff failed to report an allegation of rough treatment of a dementia resident within the required two-hour timeframe to state authorities.
Staff reported that a certified nursing assistant was observed handling a dementia resident roughly during evening care, yanking the resident and acting aggressively during undressing and personal care. The facility suspended the aide pending investigation but failed to notify the Iowa Department of Inspections and Appeals within the mandatory reporting window.
Industry Standards and Best Practices
Federal regulations require nursing homes to provide appropriate treatment according to professional standards and physician orders. This includes following individualized care plans that identify specific risks and interventions for each resident.
For residents using orthotic devices, best practices include regular skin inspection, proper device fitting, and staff training on recognizing early signs of skin breakdown. The development of infections under medical devices is often preventable through consistent monitoring and prompt intervention when problems are identified.
Consequences and Corrective Actions
The facility received citations for failing to provide needed services according to professional standards and for inadequate reporting of potential abuse incidents. Both violations indicate systemic issues with staff training, supervision, and adherence to established protocols.
MRSA infections can have serious health consequences, particularly for elderly residents who may have compromised immune systems. Early detection and treatment are crucial for preventing complications and limiting spread to other residents and staff.
The case highlights the importance of consistent implementation of individualized care plans and the potential consequences when routine safety measures are overlooked. Proper skin assessment under medical devices is a fundamental aspect of safe nursing care that requires ongoing staff education and supervision to ensure consistent implementation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rotary Senior Living from 2025-02-19 including all violations, facility responses, and corrective action plans.
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