The unauthorized treatments occurred during wound care for a resident with severe medical conditions including sepsis, systemic sclerosis with lung involvement, and Raynaud's disease. The resident, identified as R4 in inspection documents, maintained full mental capacity with a perfect cognitive assessment score of 15 out of 15.
On November 4, an inspector observed Registered Nurse E providing wound care to the resident's bilateral lower extremity wounds and a coccyx wound at 10:52 AM. The nurse removed dressings from both leg wounds and immediately sprayed them with lidocaine before beginning treatment.
Between the resident's toes, the inspector noticed a distinctive purple coloration. When questioned, the nurse explained the color came from gentian violet that staff applied every other day as part of the treatment routine.
The resident's actual wound orders, dated October 24 and November 2, specified completely different treatments. For the bilateral lower extremity wounds, orders called for cleansing, applying Iodosorb, covering with methylene blue and ABD pads, and securing with Kerlix daily. The coccyx wound required cleansing with soap and water, skin preparation around the wound area, applying Medihoney, and covering with bordered gauze every day shift.
During the observed treatment, the nurse deviated from these orders in multiple ways. After applying the unauthorized lidocaine spray, the nurse removed the coccyx dressing, cleansed the wound with soap and water as ordered, but then applied Iodosorb instead of the prescribed Medihoney.
When the inspector interviewed the nurse 33 minutes later, she revealed the facility had run out of Medihoney, which was on back order. The nurse claimed the attending physician was aware of the shortage and had given permission to substitute Iodosorb.
However, this explanation unraveled when the inspector spoke with the Director of Nursing later that afternoon. At 3:19 PM, DON-B confirmed that the resident had no physician orders authorizing lidocaine, gentian violet, or the use of Iodosorb as a Medihoney substitute.
The violations represented a complete breakdown in medication administration protocols. The resident was receiving three unauthorized treatments: lidocaine spray applied directly to open wounds, gentian violet applied between toes every other day, and Iodosorb substituted for prescribed Medihoney without proper authorization.
The resident's complex medical conditions made the unauthorized treatments particularly concerning. Systemic sclerosis with lung involvement affects connective tissue throughout the body, while Raynaud's disease causes fingers and toes to become numb and cold in response to temperature changes. Pulmonary hypertension from scleroderma further complicated the resident's health status.
Federal inspectors determined the violations created immediate jeopardy to resident health and safety, the most serious classification possible. This designation indicates that the facility's actions or failures to act have caused or are likely to cause serious injury, harm, impairment, or death to residents.
The inspection occurred as part of a complaint investigation on November 11, suggesting that concerns about care quality had been reported to state authorities. The violations affected few residents, according to the inspection classification, but demonstrated systemic failures in medication administration oversight.
The nurse's belief that verbal physician approval existed for the medication substitutions highlighted gaps in communication and documentation systems. Without written orders, nursing staff administered medications and treatments that could interact unpredictably with the resident's existing conditions and prescribed therapies.
Lidocaine, while commonly used for pain relief, requires careful dosing and monitoring when applied to open wounds. Gentian violet, an antiseptic dye, can cause skin irritation and has largely been replaced by safer alternatives in modern wound care. The unauthorized substitution of Iodosorb for Medihoney represented a fundamental change in treatment approach without proper medical supervision.
The resident's intact cognitive abilities meant they were fully aware of their treatment and capable of making healthcare decisions. The facility's failure to follow prescribed wound care protocols violated this resident's right to receive care according to their physician's specific orders.
The immediate jeopardy finding requires the facility to implement immediate corrective actions to protect resident safety. Federal regulations mandate that nursing homes cannot administer medications or treatments without proper physician authorization, regardless of supply shortages or staff assumptions about verbal approvals.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Samaritan Nursing and Rehab from 2025-11-11 including all violations, facility responses, and corrective action plans.