The resident was admitted to Creekside Post-Acute with chronic venous hypertension and ulcers on both lower legs. Venous ulcers are open sores that develop when leg veins fail to push blood back to the heart effectively.
On August 5, 2025, the wound doctor ordered specific treatment for the resident's right lower lateral leg ulcer. The instructions were detailed: cleanse the wound with normal saline, apply Xeroform sterile dressing, and cover with dry gauze and Kerlix soft gauze roll.
But those orders never reached the treatment administration record where licensed nurses look for their daily instructions.
Treatment nurse A discovered the missing orders during a federal inspection on August 22. She reviewed both the wound doctor's preliminary report from August 5 and the facility's treatment records for August 2025.
The nurse confirmed the wound doctor's orders weren't recorded in the treatment administration record. She told inspectors the resident still had the venous ulcer on his right leg and stated the wound might not receive proper treatment if orders weren't documented for licensed nurses to follow.
The breakdown occurred despite the facility's own policy requiring all drug and biological orders to be recorded on the physician's order sheet in the resident's chart. That policy dated to July 2016.
Federal inspectors found the failure had potential for the resident's wound to deteriorate and delay healing without proper treatment.
The resident's skin assessment from August 5 documented the wound doctor's specific treatment protocol. Normal saline contains 0.9 grams of salt per 100 milliliters of solution for wound cleansing. Xeroform provides a sterile, non-adhering protective barrier over wounds.
Without the treatment orders in the official record system, nursing staff lacked clear direction for the resident's daily wound care routine.
Chronic venous hypertension creates increased pressure inside leg veins, often leading to ulcers that require consistent, specialized treatment to heal properly. The condition affects blood circulation back to the heart.
The inspection occurred in response to a complaint filed against the facility. Federal inspectors classified the violation as having minimal harm or potential for actual harm to residents.
Treatment nurse A's confirmation that the resident continued to have the venous ulcer weeks after the doctor's orders were written suggests the wound persisted without proper documented care protocols.
The facility's medication and treatment order policy specifically addresses this type of documentation requirement, stating that all treatment orders must be properly recorded for staff to follow.
The missing documentation represents a breakdown in the facility's system for translating physician orders into actionable nursing care. Licensed nurses rely on treatment administration records to ensure residents receive prescribed treatments consistently.
Federal inspectors noted this deficiency affected few residents, but the impact on wound healing can be significant when treatment protocols aren't properly documented and followed.
The resident's bilateral lower extremity ulcer diagnosis required ongoing medical attention, making proper documentation of treatment orders essential for consistent care delivery.
Without the wound doctor's orders in the treatment record, nursing staff had no official guidance for the specific cleansing solution, dressing type, or covering materials required for this resident's particular wound.
The August 22 interview revealed that three weeks had passed since the wound doctor wrote the treatment orders, yet they still weren't entered into the facility's treatment administration system.
This documentation failure occurred despite the facility having established policies requiring physician orders to be recorded in resident charts, indicating a breakdown in following existing protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Post-acute from 2025-09-23 including all violations, facility responses, and corrective action plans.