Dyersburg Health & Rehab: Pressure Ulcer Failures - TN
The resident, identified only as Resident #1 in inspection records, was admitted with multiple serious conditions including osteomyelitis of the vertebra in the sacral region, a Stage 4 pressure ulcer of the sacrum, and paraplegia. Stage 4 pressure ulcers represent the most severe category, extending through skin and tissue to expose bone, muscle, or tendons.
Physician orders from May 11, 2024, prescribed a complex daily wound care regimen. Staff were instructed to clean the left groin wound with skin prep solution, then mix silver sulfadiazine cream with crushed Flagyl antibiotic and apply it to the wound bed. The treatment required packing with Dakins-soaked Kerlex gauze, covering with an abdominal pad, and securing with tape once daily and as needed.
But documentation gaps persisted across three months of treatment records.
In May 2024, treatments went undocumented on five separate days: the 16th, 22nd, 24th, 27th, and 30th. June proved worse, with nine undocumented days including the 5th, 6th, 10th, 14th, 15th, 19th, 28th, 29th, and 30th. July continued the pattern with seven more gaps on the 3rd, 4th, 6th, 10th, 11th, 21st, and 25th.
The resident remained cognitively intact throughout this period. A quarterly assessment showed a Brief Interview for Mental Status score of 15, indicating normal cognitive function and the ability to understand and participate in care decisions.
Facility policy explicitly required documentation of all wound treatments. The Wound Treatment Management policy, dated December 3, 2024, stated that wound treatments would be provided according to physician orders and documented on the Treatment Administration Record.
During an October 6 interview, inspectors questioned the Director of Nursing about proper documentation procedures. When asked whether patient refusals of wound care should be documented, the director replied, "Yes."
The director was then asked whether the Treatment Administration Record should ever show blank days for wound care.
"No, it should be documented completed unless it was refused and then it should be documented as refused," the director stated.
Yet the records showed exactly what the director said should never happen. Multiple blank entries across three months with no indication whether treatments were provided, refused, or missed entirely.
The documentation failures created a dangerous gap in the resident's medical record. Without proper documentation, subsequent caregivers had no way to verify whether the complex antibiotic regimen was consistently administered. The resident's condition required precise tracking given the severity of both the Stage 4 ulcer and the underlying bone infection.
Silver sulfadiazine and Flagyl represent serious medications requiring careful monitoring. Silver sulfadiazine can cause skin discoloration and allergic reactions, while Flagyl carries risks of neurological side effects with prolonged use. The combination therapy suggested the wound's severity demanded aggressive treatment.
The inspection occurred nearly six months after the most recent documentation gaps, suggesting the problems persisted long enough to generate the complaint that triggered federal scrutiny.
Federal investigators classified the violation as causing minimal harm or potential for actual harm, but noted it affected the facility's ability to demonstrate consistent care for pressure ulcer patients. The finding represents a failure to meet professional standards of practice for wound care documentation.
For Resident #1, the undocumented periods meant weeks where no official record existed of whether the prescribed antibiotic treatments reached the infected bone and tissue. The resident's paraplegia already limited mobility and healing capacity, making consistent wound care even more critical.
The facility's own policy promised treatments would be documented on the Treatment Administration Record. Instead, that record became a patchwork of gaps spanning the very months when aggressive intervention was most needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dyersburg Health and Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DYERSBURG HEALTH AND REHABILITATION CENTER in DYERSBURG, TN was cited for violations during a health inspection on November 20, 2025.
Stage 4 pressure ulcers represent the most severe category, extending through skin and tissue to expose bone, muscle, or tendons.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.