Park View Rehab: Failed to Report Worsening Wounds - IA
Park View Rehabilitation Center failed to notify the resident's representative about the worsening condition, despite facility policy requiring immediate notification when wounds change, federal inspectors found during a September complaint investigation.
The resident suffered from memory problems and severely impaired cognitive skills following a stroke that left the right side paralyzed. The care plan identified risk for skin breakdown due to immobility, stroke-related weakness, and blood-thinning medications.
Initial pressure ulcers developed on July 30 on the right buttock and August 15 on the left buttock.
By August 21, the weekly skin assessment revealed alarming deterioration. The left buttock showed a reddish-purple area measuring 2.7 cm by 2 cm with yellow tissue death. The right buttock wound had become an open area measuring 8 cm by 10.5 cm with yellow dead tissue around the edges and brown discolored skin in the center.
Staff faxed the physician about the worsened wounds on August 22. The doctor's response confirmed receipt of the notification.
But the family never heard from the facility.
On August 29, the resident's family member filed a concern form stating she felt the facility had not notified her about the wound worsening. She had given this report verbally and in person to staff.
Staff C, a licensed practical nurse, told inspectors on September 3 that she normally conducted wound assessments on Thursdays and then faxed results to doctors. She acknowledged the resident's wounds had been deteriorating.
The clinical record contained no documentation that the resident's representative received any notification about the significant change in wound condition.
Park View's notification policy, revised in June 2023, clearly states the facility must immediately inform the resident, consult with the physician, and notify the resident's representative when there is a significant change in physical, mental, or psychosocial status.
The facility reported a census of 43 residents during the inspection. Inspectors reviewed notification practices for four residents and found the failure affected one case.
Federal regulations require nursing homes to immediately tell residents, their doctors, and family members about situations that affect the resident, including injuries and decline in condition.
The deterioration from initial pressure ulcers to large open wounds with tissue death represents exactly the type of significant change that demands family notification. The resident's cognitive impairment and stroke-related paralysis made family involvement in care decisions particularly critical.
Park View's failure meant the family member learned about the serious wound deterioration only after filing a formal complaint, weeks after the condition had worsened substantially.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Rehabilitation Center from 2025-09-04 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 20, 2026 · Our methodology
Park View Rehabilitation Center in Sac City, IA was cited for violations during a health inspection on September 4, 2025.
The resident suffered from memory problems and severely impaired cognitive skills following a stroke that left the right side paralyzed.
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.