The resident had undergone a breast biopsy that left her with a surgical incision. On October 16, nurses discovered the wound had dehisced, meaning it had split open. Staff immediately called the physician and received orders for a seven-day course of antibiotics, triple antibiotic ointment, and dry dressing changes.
But nobody called the family.
For nearly a week, the resident received antibiotic treatment while her family remained unaware of the complication. The facility's own policy, dated November 28, 2017, requires staff to "promptly inform the resident" and "notify the resident's representative when there is a change requiring notification," including new treatment.
On October 22, the family finally learned what had happened — through a text message they sent to a registered nurse. The family had been informed by the resident herself that her surgical incision was open and infected and that she was taking antibiotics. In that same text conversation, the family requested the resident be sent to the hospital for follow-up care.
Only then did staff document that they had contacted the resident's representative about the dehisced surgical wound and current treatment orders.
The resident, identified in inspection records as having intact cognition, had been dealing with multiple health challenges. Her medical history included stroke with right-side weakness, seizures, and the recent breast biopsy that led to the open wound. Despite her cognitive clarity, she had to serve as her own advocate when the facility's communication system failed.
During interviews with federal inspectors, facility administrators acknowledged the breakdown. The administrator and a registered nurse explained that Licensed Practical Nurse D, who was working the floor that day, had properly called the physician but failed to call the family about the resident's change in condition.
The resident had already been on antibiotics for several days when her family reached out via text message, having just learned from the resident about her condition.
When inspectors asked what the facility's expectations were for family notification, the administrator and another registered nurse were clear: they would expect staff to notify family "as soon as possible when a resident has a change in condition and definitely before their shift is over."
The gap between policy and practice was stark. The facility's written guidelines specifically identify "new treatment" as a circumstance requiring notification. The antibiotic course, ointment application, and specialized wound dressing all constituted new treatment that should have triggered immediate family contact.
Federal inspectors reviewed three residents' cases as part of their sample, with 74 residents living at the facility during the inspection. The violation affected what inspectors classified as "few" residents, though the impact on this particular family was significant.
The resident's surgical wound had opened on a Thursday. By the following Wednesday, when her family finally learned of the complication, she had been receiving medical treatment for an infected wound for nearly a week without their knowledge. The family's immediate request for hospitalization suggests they viewed the situation as serious enough to warrant emergency-level care.
Mary, Queen and Mother Center's notification policy emphasizes compliance with federal guidelines requiring facilities to inform residents, consult with physicians, and notify family members or legal representatives when changes occur. The policy acknowledges that proper notification is essential for ensuring residents receive appropriate care and that families can make informed decisions about their loved ones' treatment.
The facility's failure to follow its own notification procedures left a cognitively intact resident in the position of having to inform her own family about a serious medical complication. While she was able to communicate the situation, the six-day delay meant her family was excluded from treatment decisions during the critical early stages of wound infection management.
The inspection, conducted on November 4, 2025, was prompted by a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but the case illustrates how communication failures can undermine family involvement in care decisions even when residents retain their mental faculties.
The resident's family had to learn about her infected surgical wound through her own report, then advocate via text message for hospital-level care that the facility had not offered during the six days they were treating the complication without family knowledge.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mary, Queen and Mother Center from 2025-11-04 including all violations, facility responses, and corrective action plans.
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