The resident, identified as CR #1, had blood visible in his pull-up diaper that staff attributed to a UTI rather than conducting the thorough skin assessment required by facility policy. Family members ultimately discovered the abscess.
During an interview on November 19, the Director of Nursing told inspectors they "believed CR #1's tinge of blood was a UTI but found out he had an abscess that had not ruptured yet." She acknowledged that "facility staff had not seen an abscess on CR #1."
The facility's own skin assessment policy, dated October 1, requires licensed nurses to conduct full body skin assessments upon admission and weekly thereafter. The policy specifically instructs staff to "begin head to toe, thoroughly examining the resident's skin for condition" and "pay close attention to pressure points, bony prominences, and underneath medical devices."
But staff interviews revealed gaps in following these procedures.
A certified nursing assistant who helped CR #1 shower on August 29 told inspectors she "did not see his private area" during the bathing process. She said CR #1 "washed in between his private area and underneath his balls (testicles)" himself, and she observed "no blood on the white bath towel or in his pull up."
The CNA said she would have reported any areas of concern to the nurse, but the resident showed no signs of pain during their interaction.
However, the resident's physician told inspectors that abscesses can develop quickly and produce recognizable symptoms. In an interview on November 19, the doctor said "an abscess could absolutely pop up overnight and the resident would show signs that something was there." He identified fever, pain, and general discomfort as typical warning signs.
The Administrator acknowledged during her November 19 interview that "the area was a boil and the resident would not allow the staff to wash him." She said during showers "there was nothing on the washcloth," suggesting staff weren't able to properly examine all areas of the resident's body.
This resistance to care appeared to influence how thoroughly staff conducted required assessments. The Administrator told inspectors that "head to toe skin assessments should be completed regularly and were based on the patients' behavior and compliance."
But the Director of Nursing emphasized the importance of comprehensive examinations regardless of resident cooperation. She told inspectors that nurses "should look at the creases, moist areas, folds, and every inch of the body during a head-to-toe skin assessment" because "those areas of the body were more susceptible to bacteria."
When asked about potential consequences of incomplete skin assessments, a CNA interviewed on November 19 said she "was unsure of what could happen if every part of the resident's body was not examined during a head-to-toe skin assessment."
The same CNA described her training on skin assessments, saying she was instructed to "check and look at everything" and "look at the person and review for any abnormalities or anything suspected." She understood the purpose was "to prevent any open areas, which would be reported to the supervisor and wound care nurse."
The incident prompted the facility to launch multiple corrective actions. According to an Ad Hoc QAPI Plan dated September 4, administrators implemented "head to toe assessments, in-service on ANE, in-service on skin, Inservice on continence, in-service on ADLs and dealing with difficult residents."
The Director of Nursing told inspectors that following the incident, "the facility conducted in-services, conducted a QAPI, PIP and a very thorough skin sweep." She said "the ADON, wound care nurse, and unit managers were overseeing the skin assessments."
The Administrator said the facility "always investigated concerns and 99% of the time she would take the time and re-educate staff." She characterized their investigation's conclusion as finding that "something may have been festering but the abscess just popped out."
The resident's physician provided a different perspective on the abscess's detectability. He told inspectors the abscess "was in the groin area and if it was small, it could be hard to feel," but maintained that residents typically show signs when infections are developing.
The case highlights challenges facilities face when residents refuse care or assistance with personal hygiene. The Administrator noted that CR #1 "would not allow the staff to wash him," creating barriers to the comprehensive skin assessments required by policy.
Yet federal regulations require facilities to ensure residents receive necessary care regardless of their preferences or cooperation level. The facility's policy acknowledges this responsibility, stating that full body skin assessments are part of their "systematic approach to pressure injury prevention and management."
The September QAPI plan classified the incident as "External reportable to HHSC for allegation of neglect" involving an "Abscess to resident groin." The plan noted that the "Resident refuses care and toilets himself," indicating ongoing challenges with providing comprehensive care.
Staff responses to the incident varied in their understanding of proper procedures. While the Director of Nursing demonstrated clear knowledge of comprehensive assessment requirements, front-line staff showed less certainty about the importance of complete examinations.
The facility's corrective actions included patient safety surveys, follow-up assessments, multiple staff training sessions, and enhanced oversight of skin assessments. They also implemented pain monitoring audits and head-to-toe evaluation audits to prevent similar incidents.
The case was reported to state health authorities as required for potential neglect situations. Federal inspectors classified the violation as causing minimal harm with few residents affected, but noted the facility's failure to follow its own skin assessment policies.
CR #1's abscess ultimately received medical attention after family members noticed the problem that nursing staff had missed. The resident's physician confirmed the abscess required treatment, though the inspection report doesn't detail the specific medical interventions provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Broadmoor At Creekside Park from 2025-11-20 including all violations, facility responses, and corrective action plans.
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