Parkwood Skilled Nursing: Self-Medication Rights - MO
The resident at Parkwood Skilled Nursing and Rehabilitation Center said his leg dressings were changed only three or four times the previous week, despite physician orders for daily wound care. When inspectors watched Licensed Practical Nurse D perform the treatment on November 24, the nurse ignored multiple steps in the doctor's detailed orders.
The resident suffers from diabetes, high blood pressure, and heart failure — conditions that make proper wound care critical for healing and infection prevention. Physician orders from November 15 through November 25 specified a complex daily routine: cleanse both lower legs with Vashe wound cleanser, soak for three to five minutes, apply silver wound gel to the wound bed, cover with mepitel dressing, then an ABD pad, and wrap with gauze and ace bandages.
Instead, inspectors observed LPN D skip the required soaking time entirely. The nurse cleaned the wounds with Vashe but applied silver sulfadiazine cream rather than the ordered silver wound gel. No mepitel dressing was used, and the ace wraps were completely omitted.
The resident's right lower leg showed two small open areas and one closed area. Several small open wounds covered the left lower leg. After cleaning, LPN D wrapped both legs with gauze but left off the protective ace wraps that were supposed to complete the treatment.
A day later, inspectors found the resident wearing slipper socks over the dressings. No ace wraps were in place. The resident said ace wraps had been applied only once during a previous hospital stay, never at the nursing home.
The medication confusion became clear during interviews with staff. Licensed Practical Nurse A confirmed that silver wound gel and sulfadiazine cream are different products. When LPN A checked the treatment cart, no silver wound gel was found — meaning staff had been substituting a different medication without consulting the physician who wrote the orders.
The facility's own policy from October 2023 states that when physicians give orders for residents, nursing staff must record them in the medical records and follow through within the physician's specified timeframe. The policy makes no allowances for substituting treatments or skipping steps.
During interviews on November 25, the Administrator acknowledged staff should follow physician orders and facility policies. But the pattern of missed treatments continued even as inspectors documented the violations.
The resident's experience illustrates how seemingly minor deviations from medical orders can compound into inadequate care. Diabetic patients face heightened risks of infection and delayed healing when wounds aren't properly treated. The required soaking time helps cleanse wounds, while silver wound gel provides antimicrobial protection that regular cream cannot match.
Mepitel dressings create a barrier that prevents gauze from sticking to healing tissue, reducing pain during dressing changes. Ace wraps provide compression that supports circulation and protects the wound site from further injury.
By skipping the soak, using the wrong medication, omitting protective dressings, and failing to apply compression wraps, staff left the diabetic resident vulnerable to complications that proper wound care is designed to prevent.
The inspection found 86 residents at the facility, with seven included in the review sample. Federal regulators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
But for the resident lying in bed with improperly treated leg wounds, the daily failure to follow medical orders meant facing each day with inadequate protection against infection and delayed healing that his underlying diabetes makes even more dangerous.
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 20, 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.
When inspectors watched Licensed Practical Nurse D perform the treatment on November 24, the nurse ignored multiple steps in the doctor's detailed orders.
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.