LPN #616 told the facility's wound nurse that she had checked Resident #64's skin before the appointment and found no new problems. But when the resident came back, she had developed an area on her right heel that needed medical attention.
The wound nurse, LPN #612, documented that the heel problem was "community acquired" based entirely on what LPN #616 had told her. She never examined the resident herself.
LPN #616 described the heel area as "red but blanchable" and asked the wound nurse to get a physician's order for treatment. The wound nurse contacted the primary care physician and obtained orders to apply skin prep and pad the area with foam dressing three times a week.
But LPN #616 later said she never assessed the resident's heel at all, despite telling the wound nurse she had checked the skin before the appointment.
The wound nurse said she relied completely on LPN #616's account when she documented the wound as community acquired on July 28, 2025. She never conducted her own assessment of Resident #64's heel.
Federal inspectors found the conflicting accounts during a complaint investigation at Andover Village Retirement Community on South Main Street.
The facility's own policy requires routine skin assessments for all residents. When a nursing assistant observes any skin change, they must inform the nurse, who then conducts an assessment, documents it in nursing notes, and notifies the physician and family.
None of that happened properly with Resident #64.
The wound nurse admitted she never told LPN #616 to skip documenting the heel area. She also said the director of nursing never instructed LPN #616 to avoid completing a wound assessment.
So why wasn't the assessment done?
The inspection report doesn't explain the breakdown in communication between the two nurses. LPN #616 said the area was red but blanchable and needed physician orders for treatment. But she also said she never actually assessed the heel herself.
The wound nurse took LPN #616's word that she had checked the resident's skin before the appointment and found nothing wrong. Based on that secondhand information, she classified the heel problem as something that developed outside the facility.
Federal regulations require nursing homes to assess residents' skin condition and document any changes properly. When staff give conflicting accounts about basic care procedures, it raises questions about oversight and training.
The facility policy from December 2013 is clear about the steps nurses should follow when skin problems arise. Observe the change, assess it, document it, and notify the doctor and family.
With Resident #64, the system broke down at multiple points. The LPN who was supposed to do the initial assessment said she never did one. The wound nurse who documented the problem never examined the resident herself.
The inspection was part of complaint investigations numbered 2619877 and 2603148, suggesting other residents may have experienced similar problems with skin assessment and documentation.
Inspectors classified the violation as causing minimal harm or potential for actual harm to a few residents. But the documentation failures could have more serious consequences if skin problems go unrecognized or untreated.
Proper wound assessment requires nurses to examine the actual skin condition, not rely on secondhand reports from colleagues. When a resident develops a new skin problem, determining whether it happened at the facility or elsewhere affects treatment decisions and regulatory compliance.
The conflicting stories from LPN #616 and wound nurse #612 suggest either poor communication or inadequate training in basic assessment procedures. Both are licensed professionals who should understand their responsibilities for resident care documentation.
Resident #64's heel area ultimately received medical attention through the physician's orders for skin prep and foam dressing. But the confusion about who assessed what and when highlights systemic problems with the facility's skin care protocols.
The inspection found that Andover Village failed to ensure proper skin assessments were conducted and documented according to its own policies and federal requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Andover Village Retirement Community from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Andover Village Retirement Community
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