Highland Square: Wound Care Without Doctor Orders - OH
Highland Square Nursing and Rehabilitation staff provided wound care to Resident #49, who depended on staff for all daily activities and had limited mobility in both arms and legs. The resident was frequently incontinent and required assistance with basic functions.
The facility's own wound care list showed Resident #49 was receiving treatment for an open area on his left shin. But his comprehensive care plan contained no mention of impaired skin integrity or any treatment for the shin wound.
The wound had reopened from a previous surgical repair of the resident's left tibia fracture. Visiting wound care services documented the condition on July 31, 2025, recommending daily cleansing, application of mesalt dressing material, and coverage with super absorbent padding.
Federal inspectors observed the wound care routine on August 20. At 9:13 a.m., Wound Nurse #315 cleaned the resident's wound with normal saline solution, applied mesalt, and covered it with an absorbent pad. The treatment followed the visiting service's recommendations exactly.
After the procedure, inspectors verified no physician's order existed in the medical record authorizing the wound care.
When questioned that afternoon, Wound Nurse #315 acknowledged the missing order and lack of care plan documentation. She explained her process: "She knew what the visiting wound services wanted for a treatment to the resident's shin because she rounded with them weekly, received the wound care notes and put the orders into the medical record."
But the nurse admitted she had failed to enter the order into the facility's system.
The violation meant staff had been performing medical treatments on a resident without proper authorization. Federal regulations require physician orders for all treatments, ensuring medical oversight of patient care decisions.
Resident #49's condition made proper documentation especially critical. His bilateral mobility limitations and incontinence created additional infection risks that required careful medical monitoring. The surgical nature of the wound, involving a previous tibia fracture repair, added complexity to his care needs.
The mesalt dressing material used in treatment is a specialized wound care product containing sodium chloride designed to promote healing in infected or heavily draining wounds. Its use typically requires specific medical assessment and ongoing physician oversight.
Highland Square's wound care process appeared to function through informal communication between staff and visiting specialists rather than through documented medical orders. The wound nurse's weekly rounds with visiting services created familiarity with treatment recommendations, but this system bypassed required authorization protocols.
The facility maintained a list of residents receiving wound care, suggesting systematic tracking of such treatments. However, this tracking failed to ensure proper medical orders existed before care began.
The missing documentation affected both the resident's immediate care and long-term medical record accuracy. Without orders in the medical record, other healthcare providers would lack essential information about ongoing treatments if the resident required hospital care or transfer to another facility.
Federal inspectors investigated the violation as part of complaint numbers 2579281 and 2575188, indicating concerns raised by outside parties about the facility's practices.
The wound nurse's admission that she "missed putting the order for wound care into the system" suggested the oversight was procedural rather than intentional. However, the gap between treatment provision and authorization created potential safety risks for the resident.
Wound care protocols exist to ensure medical appropriateness of treatments and prevent complications from improper care. The visiting wound service's recommendations, while professionally sound, required physician review and formal ordering to meet regulatory standards.
The violation occurred despite the facility's apparent cooperation with outside wound care specialists and the nurse's knowledge of proper treatment techniques. The breakdown happened in the administrative step of converting recommendations into authorized medical orders.
Resident #49 continued receiving the wound care during the inspection, with staff following the clinical recommendations appropriately. The treatment itself appeared medically sound, but lacked the required authorization framework.
The case illustrated how informal healthcare communication can undermine formal safety protocols, even when clinical care meets professional standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Square Nursing and Rehabilitation from 2025-08-20 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: June 21, 2026 · Our methodology
HIGHLAND SQUARE NURSING AND REHABILITATION in AKRON, OH was cited for violations during a health inspection on August 20, 2025.
The resident was frequently incontinent and required assistance with basic functions.
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.