The failure occurred at Care Village at Parkway on VFW Parkway, where federal inspectors found that supervisors knew about proper notification procedures but simply didn't follow them.
Resident #1 was transferred to the hospital emergency department on September 21. Hospital records confirmed the patient had a deep tissue injury on the right heel upon admission.
Back at the nursing home, medical records showed no documentation that anyone had notified the resident's physician about the pressure injury.
The Director of Nurses admitted the breakdown during an interview with inspectors on November 17 at 8:58 a.m. She said Nurse Supervisor #1 should have called either the resident's physician or the on-call physician about the new pressure injury on the right heel.
But nobody made the call.
Deep tissue injuries represent serious wounds that can develop into full-thickness pressure ulcers without proper treatment. They appear as purple or maroon areas of discolored skin and indicate damage to underlying soft tissue from pressure or shear forces.
The facility had already recognized the problem by the time inspectors arrived. Management had implemented an eight-point correction plan with an effective date of October 2, nearly two weeks before the federal inspection.
On September 30, facility leadership held an emergency Quality Assurance Performance Improvement meeting. They developed an action plan requiring nurses to notify physicians of any new skin alterations and document those notifications in progress notes.
The same day, the Regional Director of Clinical Operations conducted a facility-wide audit of all skin assessments. The director also ensured that providers received notification of newly identified skin concerns and that any new treatment orders were implemented.
Staff received re-education on the facility's "Change in Condition or Status Notification" policy. Licensed nurses learned they must document progress notes that include physician notification for any resident change in condition.
Resident #1 returned to the facility on October 2. This time, staff notified the physician about the skin alterations and developed a care plan that included treatment for the right heel pressure injury.
The facility instituted daily audits of all skin checks to ensure newly identified problems get reported to providers and documented in medical records. The Director of Nurses brings audit results to the quality committee monthly for three months or until compliance improves.
Federal regulations require nursing homes to immediately inform physicians when residents develop new conditions or experience changes in existing conditions. The requirement exists because prompt medical intervention can prevent minor problems from becoming serious complications.
Pressure injuries represent a particular concern in nursing homes, where residents often have limited mobility and spend extended periods in beds or wheelchairs. Without proper positioning, cushioning, and medical oversight, small areas of skin breakdown can progress to deep wounds requiring surgical intervention.
The inspection classified this as a violation causing "minimal harm or potential for actual harm" affecting "few" residents. However, the resident's transfer to the hospital emergency department suggests the injury required immediate medical attention that might have been provided earlier with proper physician notification.
Care Village at Parkway operates as part of a larger network, with regional clinical operations oversight. The involvement of corporate-level directors in the correction plan indicates the company recognized the seriousness of the communication breakdown.
The facility's rapid implementation of multiple safeguards suggests management understood that similar failures could affect other residents. Daily skin check audits and monthly quality committee reviews represent significant operational changes designed to prevent future notification lapses.
For Resident #1, the delayed physician notification meant developing a serious wound without immediate medical oversight. The deep tissue injury required hospital-level care and continued treatment after readmission to the nursing home.
The correction plan remains in effect, with the Director of Nurses responsible for ongoing compliance monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care Village At Parkway from 2025-11-17 including all violations, facility responses, and corrective action plans.