The 36-bed facility had no documentation showing they changed the woman's colostomy drainage bag according to physician orders during the nearly three weeks inspectors reviewed, from her September 19 admission through October 8.
Resident #2 was admitted with surgical aftercare needs, colostomy status, pulmonary embolism, and colon cancer. Her physician ordered the ostomy bag changed every three days and as needed.
But when inspectors interviewed her on October 8, she described the consequences of the missed care.
"Her colostomy bag had burst a couple times when she had rolled over in bed onto it," according to the inspection report.
The resident, who had intact cognition according to her admission assessment, could not recall how often staff were actually changing her colostomy bag.
The facility's Vice President of Clinical Services confirmed to inspectors the next day that there was no documentation showing the resident's colostomy drainage bag had been changed every three days per physician orders.
The Director of Nursing revealed the underlying problem during her interview on October 9. The order to change the colostomy bag appeared on the top of the treatment administration record, she told inspectors, but "was not entered correctly so staff could not document when the bag changes had been completed."
She verified there was no documentation the colostomy bag changes had been completed every three days and as needed per physician orders.
Parkview Care Center had only two residents with colostomies at the time of the inspection. Inspectors reviewed both cases but found the documentation failure affected only one resident.
The facility's own policy, revised in October 2010, required staff to document the date and time colostomy care was provided. The policy covered both colostomy and ileostomy care procedures.
A colostomy is a surgical opening in the abdomen that allows waste to exit the body when the colon cannot function normally, often following cancer surgery or other medical conditions. The drainage bag must be changed regularly to prevent leakage, skin irritation, and infection.
For a resident recovering from colon cancer surgery, proper colostomy care is essential for healing and preventing complications. The physician's order for bag changes every three days represents standard medical practice for maintaining hygiene and preventing the kind of bursting incidents the resident experienced.
The inspection occurred in response to a complaint filed with state regulators. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The documentation gap lasted from the resident's admission on September 19 through October 8 — nearly three weeks during which the facility could not prove it provided the ordered care. During this period, the resident endured multiple incidents of her colostomy bag bursting when she moved in bed.
The system failure was both administrative and clinical. While the physician's order existed in the medical record, the facility's treatment administration system was not set up correctly to allow staff to document completion of the care.
This meant even if staff were changing the colostomy bag, they had no way to record it officially. More critically, it meant supervisors had no way to track whether the essential care was actually happening.
The resident's experience illustrates how documentation failures can directly impact patient safety and dignity. A burst colostomy bag creates immediate hygiene concerns, potential skin damage, and emotional distress for residents who must live with the consequences of inadequate care systems.
The facility identified the problem during the inspection process, with both the Vice President of Clinical Services and Director of Nursing acknowledging the documentation gap to federal inspectors.
The case was investigated under complaint number 2627398, suggesting someone reported concerns about ostomy care at the facility to state health officials.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-10-09 including all violations, facility responses, and corrective action plans.