Seven Hills Rehab: Wound Care Failures - FL
Resident #8 described the facility's wound care as "very inconsistent" during a September 9 interview. She said Seven Hills Health & Rehabilitation Center was supposed to perform wound care on both sites every other day, but staff frequently missed treatments.
Her medical records confirmed the problem. Treatment administration records showed blank entries for September 4 and September 5, indicating no wound care was documented on either day. The facility's own policy requires all documentation to be completed when care is performed.
The documentation failures extended beyond missed treatments. Physician orders for Resident #8's breast wound specified daily cleaning with Dakins solution, drying, and application of Xeroform gauze with border dressing. But the treatment administration record listed the frequency as every other day instead of daily.
For her sacrum wound — classified as a full-thickness Stage 4 pressure injury — the physician ordered daily wound cleaning and application of collagen filler with calcium alginate and silver dressing. Staff entered this treatment to occur every two days instead of daily.
The wound care nurse acknowledged responsibility for the frequency errors during a follow-up interview. She confirmed the sacrum wound should have received daily treatment, not every-other-day care as documented in the administration record.
When asked about the blank documentation entries, the wound care nurse said she wasn't sure why treatments weren't recorded on September 4 and 5.
A second resident experienced similar documentation problems. Resident #3 had a physician order placed May 19 for wound care on the coccyx, but the order never appeared on the treatment administration record.
The Director of Nursing reviewed Resident #3's medical record and discovered the nurse who entered the order failed to properly categorize it. The order was placed under "other" instead of being marked for the medication administration record or treatment administration record.
She concluded the coccyx wound order should have been discontinued entirely because Resident #3 no longer had a wound in that location.
The facility's wound care policy states treatment orders must be documented on the Treatment Administration Record. The nursing documentation policy requires staff to provide "a complete account of the resident's care treatment and response to the care" with entries that are "accurate, legible, dated, and timed."
Federal inspectors found the facility violated requirements for accurate documentation and proper wound care administration. The violations affected multiple residents and created potential for actual harm.
Resident #8's breast wound required daily cleaning with Dakins solution, patting dry, and application of Xeroform gauze covered with dry border dressing. Her Stage 4 sacrum wound needed daily cleaning with normal saline, skin preparation around the wound edges, and application of collagen filler with calcium alginate and silver dressing covered by silicone superabsorbent material.
The wound care assessment documented both injuries as full-thickness wounds requiring specific treatment protocols. The breast wound treatment plan called for Xeroform gauze application every two days and as needed. The sacrum pressure wound required alginate calcium with silver application once daily and as needed.
Despite these detailed treatment plans, staff failed to follow physician orders and left critical documentation blank during multiple treatment days.
The Director of Nursing acknowledged the order frequency errors and promised to fix the documentation problems. She confirmed all wound care documentation should be completed at the time treatments are performed.
The inspection occurred September 9 following a complaint about the facility's wound care practices. Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest level of physical well-being and prevent deterioration of their condition.
Resident #8's experience illustrated the human impact of inconsistent wound care. She sat for the interview knowing her last documented wound treatment had occurred six days earlier, despite physician orders requiring daily care for her Stage 4 pressure injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seven Hills Health & Rehabilitation Center from 2025-09-09 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 19, 2026 · Our methodology
SEVEN HILLS HEALTH & REHABILITATION CENTER in TALLAHASSEE, FL was cited for violations during a health inspection on September 9, 2025.
Resident #8 described the facility's wound care as "very inconsistent" during a September 9 interview.
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.