The breakdown in communication at Clayton Rehabilitation and Healthcare Center left Resident 18, who had Parkinson's disease and severe dementia, without proper wound protection after developing new pressure sores on his left thigh and right heel.
Physician Assistant 1 discovered the deteriorating condition during a Monday examination. The resident had become more confused and lethargic over the weekend, with decreased food intake. She found the left thigh wound appeared bruised with significant redness and suspected infection.
"The area of skin breakdown was on the left hip," PA 1 told inspectors during an interview. "The left hip looked bruised as well as having the sore on the hip."
She started the resident on antibiotics and gave specific verbal instructions to the primary nurse: keep the resident off the left hip, keep the area covered, and consult the facility wound nurse.
But the message never reached the people caring for him.
Nurse 10 worked with Resident 18 for 16 hours that Monday, from 7 AM to 11 PM, then returned the next day for an eight-hour shift. When inspectors interviewed her twice about the physician assistant's orders, she said she didn't recall receiving any instructions about keeping the hip wound covered or positioning the resident off his left side.
The nurse knew the resident had no skin breakdown when she last worked with him before that Monday. She first became aware of the wound area on Tuesday, when she found it already covered, but didn't know who had applied the dressing or when.
Nurse Aide 6 cared for Resident 18 during the day shift on Monday. She told inspectors she didn't recall any skin breakdown while caring for him.
Nurse Aide 10 worked the evening shift that Monday, from 3 PM to 11 PM. She also said she didn't recall the wound.
The facility's own wound physician had been treating another resident, Resident 1, and told inspectors that missing dressing changes could cause harm to patients with multiple medical conditions. Diabetes, congestive heart failure, and chronic obstructive pulmonary disease can all contribute to oxygen problems that interfere with wound healing.
Resident 18 had several of these same conditions, along with Parkinson's disease, dementia, anemia, and osteoarthritis. His admission assessment coded him as severely cognitively impaired and dependent on staff for turning in bed. He already had one unstageable pressure sore when he arrived at the facility.
The development of new pressure sores within days of his admission, combined with the communication breakdown about his care, raised concerns about the facility's wound management protocols.
Pressure sores develop when sustained pressure cuts off blood flow to skin and underlying tissue. For residents who cannot reposition themselves, staff must follow specific turning schedules and positioning instructions to prevent further damage.
PA 1's orders were medically appropriate for the situation she found. Keeping weight off the infected area would reduce pressure and allow healing. Covering the wound would protect it from contamination and further injury.
The failure of multiple staff members to remember or act on these critical care instructions left Resident 18 vulnerable to worsening infection and additional tissue damage.
Federal inspectors classified the violation as causing actual harm to a few residents, indicating that the facility's wound care communication failures resulted in documented patient injury.
The inspection revealed a pattern where physician orders failed to reach the bedside caregivers responsible for implementing them, creating gaps in care that could affect any resident requiring specialized wound management or positioning protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clayton Rehabilitation and Healthcare Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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