Resident 108 lay in bed at Alamo Nursing Home with an actively bleeding wound on her right buttock when CNA Y performed what inspectors called improper care. The assistant rolled up the wet pad underneath the resident and pulled it out from under her body, despite facility knowledge that this pulling motion causes shearing — where surface skin separates from underlying tissue.
The wound stretched approximately four inches long as a bright red linear opening with dead tissue around it. CNA Y reported the red wound was new, appearing since the previous day.
Unit Manager X, who assessed the wound alongside a wound care provider the day before, said it looked "much worse" when she observed it again on September 17. She pointed out that while staff knew about a small superficial round wound on the lower right buttock, the area of dead tissue and the bright red linear wound were entirely new.
"Staff should not pull the linens, pads or briefs out from under the resident due to potential for shearing," Unit Manager X told inspectors, acknowledging the exact technique she had just witnessed CNA Y perform.
The resident required enhanced barrier precautions due to her wounds and catheter, but no sign was posted at her door to alert staff. Neither CNA Y nor LPN OO wore gowns before providing direct care, violating infection control protocols.
CNA Y applied barrier cream directly over the wounds from a tube sitting on the resident's nightstand. She reported that the day before, the barrier cream had gone missing, though nursing assistants normally applied it during incontinence care.
The resident remained continent of bowel and bladder and did not use incontinence briefs, according to CNA Y.
LPN OO, who frequently worked the resident's hallway, reported she had never observed the buttock wound. LPN BB said she also had not seen the wound, explaining that her hall was "very busy and difficult to get through medication pass."
CNA DD, who worked with Resident 108 during the previous night shift, described the wound as "red, elongated and had yellow open areas." She said the resident experienced pain from the wound and reported using spray wound cleanser and applying barrier cream once during the night.
Director of Nursing B confirmed that Resident 108 was cognitively intact and capable of verbalizing events related to her care. She emphasized that nursing staff should administer all wound care treatment orders to ensure nurses routinely observed wounds.
After inspectors documented the worsening condition, Unit Manager X spoke with the medical provider and changed the wound care orders. The facility switched to Medi Honey, a topical medication that promotes moist wound healing and removes dead tissue, covered with a bandage.
The new physician orders, dated September 18, classified the injury as a "right gluteal unstageable wound" — a pressure injury where depth cannot be determined due to dead tissue covering the area. The orders specified cleansing with wound cleanser, applying Medi Honey and collagen to maintain moisture, and covering with border gauze each morning.
Unit Manager X applied the new wound dressing after the order change.
The inspection revealed that nursing assistants routinely applied barrier cream to wounds during incontinence care without nursing supervision, despite the Director of Nursing's statement that all wound care should be administered by nursing staff for proper monitoring.
Federal inspectors found the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, resulting in actual harm to few residents.
The case highlighted gaps between facility policies and actual practice. While managers understood proper wound care techniques and the risks of shearing, front-line staff continued using methods known to worsen skin injuries.
Resident 108's wound progression from a small superficial injury to a 4-inch actively bleeding wound with dead tissue occurred under the care of staff who had access to appropriate supplies but lacked consistent oversight of wound care procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alamo Nursing Home Inc from 2025-09-22 including all violations, facility responses, and corrective action plans.