Abbeyville Skilled Nursing: Wound Care Missed for 4 Residents - PA
Inspectors visited the facility on August 19, 2025, following a complaint. What they found, across six resident records they reviewed, was a pattern of skipped treatments for some of the most vulnerable wounds a nursing home resident can have: surgical amputation sites, a coccyx wound, shin abrasions, a foot wound on a diabetic-type regimen. Four of the six residents had documented orders for wound care that simply did not happen, with no explanation recorded anywhere in their charts.
The Director of Nursing confirmed it at approximately 4:00 p.m. on August 4th, the day inspectors were reviewing records. Four of six residents had not received their prescribed wound treatments.
The residents are identified in the inspection report only by codes, but their conditions are detailed enough to make clear what was at stake.
One resident, identified as R3, had a left foot wound being treated with a specific regimen: cleanse with Vashe solution, pat dry, apply Therahoney, a medical-grade honey used in wound care, then cover with bordered gauze. A physician had ordered that treatment on July 26th. The treatment administration record for August showed a gap on August 2nd. No progress note explained the absence.
A second resident, R4, had been admitted with heart failure, peripheral vascular disease, and the surgical removal of toes on the right foot. Peripheral vascular disease narrows the blood vessels and reduces circulation to the limbs, which means wounds in the feet and legs heal poorly and deteriorate quickly without consistent care. This resident had two active wound orders: one for the right foot amputation site, requiring the incision to be cleansed with saline, covered with a special dressing and wrapped with kling bandage every day shift, and a second for a wound at the coccyx, requiring zinc-oxide barrier cream and a bordered foam dressing, also every day shift. Neither wound was treated on August 2nd. The care plan, which had been started on July 30th, noted that R4 was at risk for skin breakdown and had an anterior foot amputation and a coccyx wound. It listed no goals and no interventions for the actual wounds already present.
The third amputation patient, R5, had diagnoses of leukemia, deep vein thrombosis, and syncope. This resident had a right foot amputation site requiring daily incision care, and separately, bilateral shin abrasions being treated with Xeroform gauze, a medicated dressing, covered with bordered gauze. Both treatments were ordered. Neither was documented as completed on August 3rd. The care plan noted R5 was at risk for skin breakdown and directed staff to observe the skin for signs of deterioration. It said nothing about treating the wounds that already existed.
Leukemia affects the body's ability to fight infection and can impair healing. A blood clot in a deep vein, which R5 also carried as a diagnosis, affects circulation in the legs. These are not residents with ordinary skin. Missed wound care for patients like this is not a paperwork problem.
The inspection report does not say what happened to any of these residents' wounds afterward. It does not say whether any wound worsened, whether any resident reported pain, or whether anyone on staff noticed the treatments had been skipped before inspectors arrived to ask. The progress notes, the place where a nurse would document a reason for deviating from a physician's order, were silent.
The facility's own care plan for R4 captured something inspectors returned to in their findings: the document acknowledged the resident had actual skin breakdown, not just a risk of it, and still contained no goals or interventions for that breakdown. The plan was started the same day as one of the wound care orders. The orders and the care plan existed simultaneously, one directing daily treatment, the other saying nothing about it.
Abbeyville Skilled Nursing and Rehabilitation Center is located at 100 Abbeyville Road in Lancaster. The deficiency was cited at a level of minimal harm or potential for actual harm.
The Director of Nursing did not dispute the findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Abbeyville Skilled Nursing and Rehabilitation Cent from 2025-08-19 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 4, 2026 · Our methodology
ABBEYVILLE SKILLED NURSING AND REHABILITATION CENT in LANCASTER, PA was cited for violations during a health inspection on August 19, 2025.
Inspectors visited the facility on August 19, 2025, following a complaint.
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.