The resident arrived at the facility on September 12 with hospital discharge instructions that clearly outlined daily wound care requirements. The instructions called for cleaning the left hip incision site with Vashe cleanser, patting it dry, and covering it with an antibacterial dressing and protective cover daily and as needed.
Nobody implemented those orders.
The facility didn't establish a physician's order for the surgical wound treatment until September 15 — three full days after the resident's admission. During those 72 hours, the patient received no documented wound care despite arriving with an active infection serious enough to require hospitalization.
State inspectors launched their investigation after receiving a complaint on October 8 alleging the facility had not properly cared for the resident's wound. The complaint prompted a review that revealed the gap in treatment immediately following the patient's hospital discharge.
The resident had been diagnosed with sepsis caused by Serratia, a type of bacteria that can cause severe infections. Hospital records show medical staff provided specific discharge instructions for ongoing wound management, including the use of Vashe cleanser — a specialized solution designed to remove germs, dirt and dead tissue without damaging healthy tissue.
When inspectors interviewed the unit manager on November 13, the Licensed Practical Nurse acknowledged that surgical wound care instructions were clearly noted on the hospital continuity of care document the facility received on September 12. She confirmed the treatment wasn't implemented until September 15.
A nurse practitioner told inspectors during a telephone interview the same day that she would have expected the wound treatment order to be implemented immediately upon the resident's admission on September 12, based on the information in the hospital discharge documentation.
The Director of Nursing Services could not provide evidence that any surgical wound treatment order had been implemented when the resident arrived at the facility.
The three-day delay violated professional standards of care for post-surgical patients, particularly those recovering from sepsis. The hospital had established a clear protocol requiring daily wound cleaning and dressing changes to prevent infection and promote healing in a patient already compromised by systemic infection.
Federal regulations require nursing facilities to provide necessary treatment and care that meets professional standards of quality. The failure to implement hospital discharge orders for wound care represents a breakdown in the admission process that left a vulnerable patient without prescribed medical treatment.
Vashe cleanser, specifically ordered by the hospital, is formulated for surgical wounds and infected sites. The delay in implementing its use meant the surgical incision went without the specialized cleaning designed to prevent further bacterial contamination in a patient whose immune system was already fighting a serious infection.
The resident's sepsis diagnosis indicated their body was responding to a severe infection that had entered the bloodstream. Proper wound care becomes critical for such patients, as any additional bacterial exposure through an untreated surgical site could worsen their condition or delay recovery.
State inspectors found the facility's failure affected few residents but determined it caused minimal harm or potential for actual harm. The finding represents a violation of federal quality standards that require nursing homes to provide treatment consistent with professional medical practices.
The investigation revealed a gap between hospital discharge planning and nursing home implementation that left a sepsis patient without prescribed wound care during a critical period of recovery. The resident spent three days at Elmhurst without the daily wound cleaning and dressing changes that hospital physicians had determined were necessary for proper healing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elmhurst Rehabilitation and Healthcare Center from 2025-12-01 including all violations, facility responses, and corrective action plans.