The resident required multiple daily treatments for wounds on the left upper inner thigh, right lower abdomen, and left lower extremity. Orders included cleansing wounds with Dakins solution, applying mupirocin ointment, and covering with border gauze twice daily.
But treatment records showed blank spaces on March 6, 7, 11, 17, 18, 20, 21, and 27 for day shifts. No documentation appeared in progress notes explaining the gaps.
The resident also missed a required skin assessment on March 17, with another blank space in the electronic treatment administration record.
Additional wound treatments for the left lower extremity went undocumented on March 10 and 16, again with no explanatory notes in the medical record.
When federal inspectors questioned staff about the gaps during a September complaint investigation, nursing supervisors were unequivocal about what blank spaces meant.
"There should never be blank spaces," the nursing supervisor told inspectors on September 16. When asked why, the supervisor answered that "blanks indicated that the treatment was not documented which meant the treatment was not performed."
The Director of Nursing echoed this interpretation. She stated that "there should be no blanks on the eTAR and that if it was not documented, the treatment was not done."
She confirmed the blanks existed when inspectors showed her the resident's treatment record.
The facility's own policy, dated May 1, 2024, requires that "documentation should occur promptly after providing care." It states that proper documentation "provides a clear, consistent record of care" and "ensures continuity of care for residents."
The policy allows for late entries but requires they be "clearly noted" with explanations for delays. No such explanations appeared for any of the missing documentation.
A registered nurse interviewed by inspectors said treatments should be signed on the electronic record after administering them to residents. The nurse acknowledged "there should not be any blank spaces on the eTAR."
The Director of Nursing told inspectors her expectation was that "all documentation was completed prior to the end of the nurse's shift."
The missed treatments involved multiple medications prescribed for the resident's various wounds. Orders included clotrimazole-betamethasone cream for the abdomen and left upper thigh, collagen external cream, bacitracin, and hydrocortisone gel for a head rash.
Some treatments dated back months. The mupirocin orders for thigh and abdomen wounds were written January 7. The gentamicin cream for the lower extremity wound dated to March 22 of the previous year.
The hydrocortisone gel for the head rash was prescribed March 7, just one day after the first documented gap in treatment administration.
Federal inspectors found the violations during a complaint investigation at the 120-bed facility. The inspection report classified the harm level as minimal, affecting few residents.
But the facility's own nursing leadership made clear that undocumented care means no care was provided. By that standard, a resident with multiple wounds went without prescribed treatments for more than a week, with no medical justification recorded for the gaps.
The resident required complex wound care involving cleaning solutions, topical antibiotics, and protective dressings. Missing even single applications of such treatments can delay healing and increase infection risk.
Excel Care at the Pines has not publicly responded to the inspection findings. The facility must submit a plan of correction to federal regulators detailing how it will prevent similar documentation failures.
The nursing supervisor's stark assessment during the inspection leaves little room for interpretation about what happened during those March days when treatment records remained blank.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excel Care At the Pines from 2025-09-16 including all violations, facility responses, and corrective action plans.