SAINT LOUIS, MO - Federal inspectors cited Hillside Manor Healthcare and Rehab Center for failing to follow proper wound care protocols after staff discovered a diabetic ulcer on a resident's heel but failed to obtain physician orders or monitor the wound according to facility policy.
The March 20, 2025 inspection revealed that a resident with diabetes and peripheral vascular disease developed a wound on the back of their right heel that went largely undocumented and untreated despite the facility's own comprehensive wound management protocols.
Wound Discovery and Documentation Failures
The resident, identified as Resident #27 in inspection documents, has multiple risk factors that make wound care critical. Their medical history includes diabetes mellitus and peripheral vascular disease, conditions that significantly impair healing and increase infection risk. The resident requires maximum assistance with daily activities including toileting, showering, and dressing.
On March 8, 2025, facility staff noted a wound to the resident's right heel on the 24-hour shift report. However, this notation did not trigger the proper response protocols outlined in the facility's own wound management policy. No progress notes were documented regarding the wound from March 8 through March 19, and no physician orders were obtained for treatment.
When inspectors visited on March 20, they observed the facility's Director of Nurses, Assistant Director of Nurses, and a wound care nurse practitioner assess the resident. The wound care specialist identified the injury as a diabetic ulcer measuring 0.6 centimeters by 0.6 centimeters by 0.3 centimeters in depth, with 90% granulation tissue and 10% slough.
Policy vs. Practice Disconnect
The facility's wound management policy, revised in October 2022, established clear protocols for wound identification and treatment. According to the policy, licensed nurses must perform skin assessments weekly and upon identification of any wound must immediately measure it, initiate monitoring records, and notify the attending physician for treatment orders.
The policy specifically requires that "the attending physician will be notified to advise on appropriate treatment promptly" and that nursing staff must "develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician."
Despite these written protocols, staff failed to implement basic wound care procedures. No treatment orders appeared on the resident's physician order sheet for March 2025, and no treatments were documented on the treatment administration record.
Staff Awareness Issues
Interviews with facility staff revealed concerning gaps in communication and awareness. A certified nursing aide who had assisted with the resident's care stated they were unaware of the wound and could not remember which colleague they had worked with during the resident's shower.
The Assistant Director of Nurses told inspectors they were unaware of the wound and had not seen it documented on daily reports. According to facility policy, staff should document any changes in resident condition in progress notes and obtain treatment orders when wounds are discovered.
Medical Implications of Delayed Care
Diabetic ulcers require immediate attention due to the high risk of complications in patients with diabetes and circulation problems. Peripheral vascular disease, which this resident had, reduces blood flow to extremities and significantly impairs the body's ability to heal wounds and fight infections.
When diabetic wounds go untreated, they can progress rapidly from minor injuries to serious complications including cellulitis, bone infections, and in severe cases, may require amputation. The combination of diabetes and poor circulation creates a medical emergency requiring prompt intervention.
Proper wound care protocols exist specifically because early intervention can prevent minor wounds from becoming life-threatening complications. The facility's policy recognized these risks by requiring immediate physician notification and comprehensive documentation.
Regulatory Standards and Expectations
Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. Facilities must have systems in place to identify wounds early and ensure proper treatment protocols are followed.
The inspection revealed violations of wound care standards that put vulnerable residents at risk. Proper wound management requires coordination between nursing staff, physicians, and specialized wound care professionals to ensure optimal healing outcomes.
Hillside Manor Healthcare and Rehab Center must submit a plan of correction to address these deficiencies and demonstrate how they will ensure proper wound identification, documentation, and treatment protocols are followed consistently for all residents.
The facility serves 145 residents and is required to maintain compliance with federal standards for resident care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillside Manor Healthcare and Rehab Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
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