The resident at Salmon Creek Post Acute & Rehabilitation had diabetes and peripheral vascular disease, a condition that narrows blood vessels and reduces blood flow to the legs. Federal inspectors found the facility failed to follow doctor's orders for wound care treatments between July and August.
The resident had moderately impaired cognition and required daily wound care for three open areas on the left lower leg, an open area on the buttocks, and damaged skin on the right heel, according to the care plan from August 20.
Doctor's orders called for specific daily treatments: cleaning bilateral heel wounds with normal saline, applying calcium alginate dressing to absorb drainage, and covering with bordered foam dressing. A second order required covering heel wounds with Betadine-soaked gauze, adding dry gauze on top, and wrapping in rolled gauze to secure the dressings.
The resident didn't receive these treatments on July 16, August 6, August 11, and August 16, according to medication and treatment administration records reviewed by inspectors.
Staff provided no documentation explaining why the resident missed wound care on July 16, August 11, and August 16. Progress notes covering June through early September contained no record that treatments were given or missed on those dates.
On August 6, an outside provider delivered wound care, but nurses failed to document this on the facility's treatment administration record. The lapse meant the facility's own records showed the resident received no wound care that day, even though treatment occurred.
Staff B, the registered nurse serving as interim director of nursing, told inspectors during an October 9 interview that nurses were expected to administer medications and treatments according to provider orders.
The facility's own medication administration policy, dated January 2023, requires medications and treatments to be given according to written prescriber orders. The policy also mandates that whoever administers medication or treatment must record it on the resident's record immediately afterward.
For diabetic residents with peripheral vascular disease, consistent wound care is critical. The combination of high blood sugar and reduced blood flow to extremities makes healing difficult and increases infection risk.
The inspection found the medication error affected few residents, but placed those residents at risk of adverse medical conditions, changes in health status, and diminished quality of life.
Federal inspectors conducted the complaint investigation on November 18, finding the facility failed to ensure residents were free from significant medication errors when treatments weren't administered according to doctor's orders.
The missed treatments occurred over a two-month period for a resident whose medical conditions made consistent wound care essential for preventing complications and promoting healing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salmon Creek Post Acute & Rehabilitation from 2025-11-18 including all violations, facility responses, and corrective action plans.
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