The failure at Nans Pointe Rehabilitation and Nursing stretched across three days in October, as the resident's wound deteriorated and staff repeatedly documented plans to start treatment that never materialized.
Resident #2's infected diabetic ulcer on their right foot had tested positive for three types of bacteria: Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis. Lab results arrived at the facility showing the bacterial growth, prompting the wound care nurse practitioner to order immediate IV antibiotic treatment.
The wound was deteriorating rapidly. By October 20, the nurse practitioner documented that the right foot plantar wound measured 2.1 cm x 1.5 cm x 0.7 cm, had developed new tunneling, and was producing heavy bloody drainage. The wound contained a mixture of dermis, granulation tissue, and epithelium.
After reviewing the lab results that day, medical staff ordered Linezolid 600 mg to be given intravenously twice daily for three days, followed by a reduced dose due to the resident's kidney function. The first dose was scheduled for 8:00 AM on October 21.
The medication never came.
The Unit Manager confirmed during an October 22 interview that on October 21 at 8:00 AM, "the resident had IV access, and the medication was available for administration." She could not explain why it was not given.
By the evening dose at 8:00 PM on October 21, the IV line had become dislodged. Staff documented this as the reason for missing that dose.
The next morning at 8:00 AM on October 22, the resident still had no IV access. The line remained dislodged, and again no antibiotic was administered.
Staff finally inserted a new IV at 10:32 AM on October 22. The antibiotic was still not given.
A nurse's note at 1:00 PM that same day stated the resident "was to start the antibiotic that day." It was not administered.
By October 23, after three full days without the ordered antibiotic treatment, a consulting physician recommended discontinuing the medication entirely. Instead, the doctor ordered blood cultures and additional lab work to assess infection markers.
The resident, who scored 13 out of 15 on cognitive testing and could make daily decisions independently, required substantial assistance with most daily activities. They needed help with bathing, dressing, transfers, and walking, and were dependent on staff for toilet transfers and putting on footwear.
A Contact Precautions sign hung above their room number, indicating the infection control measures required due to the wound's bacterial contamination.
During the inspection, federal surveyors interviewed the Unit Manager, who detailed the progression of the resident's condition and the medication orders. She described how the resident's right foot wound had presented with increased swelling and pus-filled drainage, prompting the wound culture on October 15.
When confronted with the findings on October 23, facility leadership including the Administrator, Director of Nursing, a Corporate Consultant, and the President of Operations offered no comments. They voiced no concerns about the three-day delay in antibiotic treatment for the infected diabetic wound.
The resident's wound had been ordered for MRI imaging to rule out osteomyelitis, a bone infection that can develop when diabetic foot ulcers go untreated. The bacterial growth in the wound culture represented exactly the type of serious infection that requires immediate antibiotic intervention.
Federal regulations require nursing facilities to ensure that services meet professional standards of quality. The inspection found that staff failed to meet this standard for Resident #2, whose infected wound went without prescribed treatment despite having both medication and IV access available on the first scheduled day.
The three-day span without antibiotic treatment occurred while the resident's wound showed clear signs of deterioration and heavy drainage. By the time medical staff recommended discontinuing the original antibiotic order, the opportunity for the prescribed three-day course had already passed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nans Pointe Rehabilitation and Nursing from 2025-10-23 including all violations, facility responses, and corrective action plans.
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