Parkwood Skilled Nursing: Care Quality Failures - MO
The resident, who also suffers from high blood pressure and heart failure, had physician orders requiring daily wound care with specific products and procedures. But staff at Parkwood Skilled Nursing and Rehabilitation Center repeatedly ignored those instructions during the week of November 15-25.
Federal inspectors watched Licensed Practical Nurse D change the resident's dressings on November 24. The nurse cleaned the wounds with the correct solution but then applied silver sulfadiazine cream instead of the prescribed silver wound gel. She skipped the required 3-5 minute soaking step entirely and failed to apply the ordered mepitel dressing or ace wraps.
"Silver wound gel and sulfadiazine cream are not the same," Licensed Practical Nurse A told inspectors the next day. When LPN A checked the treatment cart, she couldn't find any silver wound gel.
The resident's physician had ordered a specific daily routine: cleanse both lower extremities with Vashe wound cleanser, soak for 3-5 minutes, apply silver wound gel to the wound bed, cover with mepitel dressing, then an abdominal pad, and wrap with gauze and ace wrap.
None of that happened correctly.
When inspectors observed the resident on November 24, his right lower leg had two small open areas and one closed area. His left lower leg had several small open areas. No ace wraps were in place.
The resident told inspectors his dressings weren't changed daily. "Last week they were changed three-four times," he said. He also said he'd only had ace wraps applied once, when he was in the hospital.
The next day, inspectors found the resident wearing slipper socks over his dressings. Still no ace wraps.
The facility's own policy, revised in October 2023, requires nursing staff to write physician orders in residents' medication and treatment records and follow through with those orders in the prescribed timeframe.
The Administrator acknowledged during an interview that he would expect staff to follow physician orders and facility policies.
But that didn't happen for this resident with diabetes, a condition that makes proper wound care critical. Diabetic patients face increased infection risks and slower healing times, making adherence to prescribed treatment protocols essential.
The inspection, conducted in response to a complaint, found the facility failed to meet professional standards of quality care. While inspectors classified the harm level as minimal, the violation represents a fundamental breakdown in following medical orders.
Staff had the correct wound cleanser. They had gauze and abdominal pads. But they were missing the prescribed silver wound gel and weren't using the mepitel dressing or ace wraps ordered by the physician.
The resident's wounds required daily attention with specific antimicrobial products designed to provide a moist healing environment. Instead, he received inconsistent care with substitute medications.
Licensed Practical Nurse D went through some motions of wound care, changing gloves between legs and cleaning the wounds. But she substituted her own judgment for the physician's specific orders, using cream instead of gel and skipping the soaking step entirely.
The facility serves 86 residents. Inspectors reviewed seven residents' care as part of their sample, finding this violation affected one person.
For a resident already managing multiple serious health conditions, the failure to follow wound care orders created unnecessary risks. Open wounds on diabetic patients require precise treatment protocols to prevent complications and promote healing.
The resident remains at Parkwood, still dealing with the open areas on both legs that haven't received the prescribed care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkwood Skilled Nursing and Rehabilitation Center from 2025-11-25 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 21, 2026 · Our methodology
PARKWOOD SKILLED NURSING AND REHABILITATION CENTER in MARYLAND HEIGHTS, MO was cited for violations during a health inspection on November 25, 2025.
But staff at Parkwood Skilled Nursing and Rehabilitation Center repeatedly ignored those instructions during the week of November 15-25.
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.