The wound care consultant at Crescent Cities Nursing & Rehabilitation Center performed surgical debridement on Resident #25's sacral wound on December 24, 2024, then again on both heels in February 2025. Medical records show the practitioner wrote that "consent for the procedure was obtained from Resident #25's spouse" and that "potential risks and benefits including but not limited to scar formation, bleeding, and infection were reviewed with Resident #25's family."
None of that happened on either day.
When federal inspectors interviewed the nurse practitioner on September 12, the consultant admitted speaking to the resident's responsible party only once — a general phone call in November 2024, a month after admission. The practitioner acknowledged not contacting the family "the day of or just before performing the surgical debridement" for either procedure.
Resident #25 had suffered a stroke that left him with right-side weakness, difficulty speaking and swallowing, and cognitive communication problems. He required total assistance from staff for all aspects of his care and had a feeding tube. A wound assessment in December rated him at moderate risk for developing pressure ulcers.
The case came to light through a complaint filed with state regulators alleging that Resident #25's responsible party was never notified in advance of the wound care practitioner's plan to surgically debride the sacral wound and bilateral heel wounds.
Surgical debridement involves cutting away dead, damaged or infected tissue to promote healing. The procedure carries risks including bleeding, infection and scarring — information that federal regulations require facilities to discuss with residents or their representatives before obtaining consent.
The nurse practitioner told inspectors that patients provide "general consent to treatment" during the admission process. But federal rules require specific informed consent for surgical procedures, including explanation of risks and benefits.
The facility's medical records painted a different picture than what actually occurred. On December 24, the practitioner documented reviewing "potential risks and benefits including but not limited to scar formation, bleeding, and infection" with the resident's family before the sacral debridement. The same language appeared in February records for the heel procedures.
In both cases, the practitioner wrote that consent was "obtained verbally for wound debridement from Resident #25's spouse." The February entry specified that risks and benefits were "reviewed with facility staff" — not family members.
The discrepancy between documented consent and actual practice represents a violation of federal requirements that residents be fully informed about their health status, care and treatments. Facilities must ensure that residents or their representatives understand proposed procedures and provide informed consent.
Resident #25's case illustrates the vulnerability of nursing home patients who cannot advocate for themselves. His stroke had left him unable to communicate effectively, making him entirely dependent on staff to involve his family in medical decisions.
The complaint was filed nearly nine months after the December procedure and seven months after the February debridement. The delay suggests the family may not have learned about the surgical procedures until well after they occurred.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The finding affected one resident among 30 reviewed during the complaint survey.
The nurse practitioner's admission that no advance notification occurred directly contradicted the medical record documentation. This pattern — performing procedures first, then documenting consent that was never actually obtained — raises questions about other undiscovered cases.
Crescent Cities Nursing & Rehabilitation Center is located on East West Highway in Riverdale. The facility serves residents requiring skilled nursing care and rehabilitation services.
The inspection report does not indicate whether Resident #25's family was eventually informed about the procedures or their outcomes. The resident's medical record was closed at the time of the September review, suggesting he was no longer at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crescent Cities Nursing & Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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