Federal inspectors discovered Resident #45 on September 15 with four deep red areas across his intergluteal cleft left open to air. No dressing covered the wounds, which were supposed to be cleansed with wound solution, treated with zinc oxide, and covered with bordered dressings according to physician orders.
The resident also suffered from two arterial and venous ulcers and moisture-associated skin damage. His medical orders specifically required a pressure-reducing device for his bed and non-surgical dressings for proper wound care.
Stage III pressure ulcers penetrate through the full thickness of skin and into underlying tissue. They represent serious wounds that can lead to infection, sepsis, and death without proper treatment. The bilateral nature of this resident's wounds indicated prolonged pressure on both sides of his buttocks area.
Inspectors found the resident's buttock area red and inflamed during their 1:45 p.m. observation. The four deep red areas were clearly visible on each side of the intergluteal cleft, the natural division between the buttocks where pressure ulcers commonly develop in bedridden patients.
The facility's own wound care policy, dated October 2010, states its purpose is "to provide the care of wounds to promote healing." Yet staff failed to follow basic wound care protocols for this vulnerable resident.
Current physician orders detailed a specific treatment regimen. The stage III pressure ulcer area was to be cleansed with wound solution before zinc oxide application. A bordered dressing should have covered the treated area three times weekly. Additionally, the resident required offloading using an alternating air mattress to reduce pressure on the affected areas.
Alternating air mattresses work by inflating and deflating air cells in cycles, redistributing pressure across different parts of the body. This prevents continuous pressure on any single area, which is essential for pressure ulcer healing and prevention of new wounds.
The inspection occurred following complaints filed under numbers 2576517 and 2612561. Multiple complainants had raised concerns about wound care practices at Addison Heights Health and Rehabilitation Center, prompting federal oversight.
Pressure ulcers develop when sustained pressure cuts off blood flow to skin and underlying tissue. Residents with limited mobility face the highest risk, particularly those who cannot reposition themselves regularly. Stage III ulcers indicate tissue death has progressed beyond the skin surface into fat and muscle layers.
Without proper dressing, open wounds face increased risk of bacterial infection. Exposed tissue can dry out, preventing the moist environment necessary for healing. Foreign particles and bacteria can enter directly into the wound bed, potentially causing life-threatening complications.
The zinc oxide treatment prescribed by the physician serves multiple purposes in wound care. It creates a protective barrier against moisture and irritants while providing antimicrobial properties. Bordered dressings maintain proper moisture levels and protect the wound from external contamination.
Federal regulations require nursing homes to provide wound care that promotes healing and prevents new pressure ulcers from developing. Facilities must follow physician orders precisely and document all wound care interventions. Staff must receive proper training in wound assessment and treatment protocols.
Resident #45's condition represented a clear failure in basic nursing care. The combination of existing stage III ulcers, additional arterial and venous wounds, and moisture-associated skin damage indicated a resident at extremely high risk for complications.
The facility received citations for minimal harm with potential for actual harm affecting few residents. However, the specific resident involved faced significant risk of infection, delayed healing, and progression to stage IV ulcers, which can expose bone and require surgical intervention.
This deficiency highlighted systemic problems in wound care oversight at Addison Heights. Staff either failed to understand physician orders, lacked proper training in wound care protocols, or simply neglected their duties to this vulnerable resident.
The inspection findings revealed a dangerous gap between written policies and actual care delivery. While the facility maintained a wound care policy emphasizing healing promotion, staff failed to implement even basic wound protection measures for a resident with severe pressure ulcers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Addison Heights Health and Rehabilitation Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
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