AVON, OH. Resident #44 sat in his room with three open wounds completely exposed, despite physician orders requiring all of them to be covered with dressings.
Federal inspectors discovered the violations during a complaint investigation at Avon Place Healthcare Center on October 20, finding the resident's sacrum, right gluteal fold, and left gluteal fold wounds all uncovered while he wore only a brief.
When asked about his wound care, Resident #44 could not recall when his dressings were last changed. The licensed practical nurse responsible for his care, LPN #118, admitted she was unaware the resident lacked any wound dressings. She said the third shift was supposed to apply them.
The problems extended far beyond one resident.
Inspectors found Resident #32's wound vacuum dressing falling off, with no initials or date marking when it was applied. The resident told inspectors the wound vac was last changed on October 18 but needed changing again because it was coming loose.
Resident #48's wound dressing also lacked initials and dates. He said it was last completed October 19.
"It had been a couple of days since it was last changed," Resident #66 told inspectors about his unmarked wound dressing.
Resident #64 could not recall when his dressing was last changed. His wound covering also had no initials or date.
Two days later, inspectors returned to check on Resident #44's care during incontinence assistance. They found only one dressing present on his three wounds — covering just the sacral area. The wounds on his right and left gluteal folds remained completely exposed.
Certified Nursing Assistant #229 confirmed Resident #44 had no dressings on either gluteal fold wound. Even the single sacral dressing that was present carried no initials or date.
The violations continued. On October 23, inspectors found Resident #44 missing wound dressings on both heels, despite physician orders requiring them.
The facility's own wound care policy, last revised in October 2010, explicitly requires staff to "mark tape with initials and date and apply to the dressing after wound has been dressed." The policy mandates performing wound care per physician and wound nurse practitioner orders.
Multiple nursing staff members — from licensed practical nurses to the registered nurse manager — were directly involved in the failures. LPN Manager #121 was present when inspectors documented several residents with improperly maintained wound dressings. Registered Nurse Manager #193 was on duty when inspectors found unmarked dressings on two different residents.
The systematic breakdown in wound care protocols affected at least five residents over multiple days. Pressure sores and other wounds require consistent, sterile dressing changes to prevent infection and promote healing. Open wounds left exposed to air and contamination can quickly develop serious complications.
Resident #44's case proved particularly concerning because he had three separate wounds that should have been covered simultaneously. On one observation, all three were completely undressed. Days later, two of the three remained exposed during routine care.
The wound vacuum system failure for Resident #32 represented another serious lapse. These specialized dressings use controlled suction to promote healing and must maintain proper seal to function. A falling-off dressing renders the entire system ineffective.
Staff members consistently failed to follow basic documentation requirements. Wound dressings must be initialed and dated so other caregivers know when changes occurred and can maintain proper schedules. Without this tracking, residents risk going days without necessary dressing changes.
The violations emerged from a formal complaint investigation, suggesting family members or staff reported concerns about wound care quality. Federal inspectors classified the harm level as "minimal harm or potential for actual harm" affecting "some" residents.
Resident #44 experienced the most extensive neglect, with wounds on his sacrum and both sides of his body left untreated for multiple days. His inability to recall when dressings were last changed suggests the lapses may have extended longer than inspectors documented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avon Place Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.