The 83-bed Three Meadows Post Acute facility documented that nurses completed the wound care on November 22, but the resident's dressing still bore a November 20 date when inspectors arrived three days later.
Resident 43 told inspectors on November 25 that staff hadn't touched her surgical wound since the previous week. She said she specifically asked a nurse to change the dressing on Saturday, November 22, "but the nurse never returned to complete the dressing change."
The resident also revealed she had to request weekly that staff change the dressing on her PICC line, a central catheter inserted in her arm. "Or it would not have gotten done," she said.
Her physician had ordered wound care three times per week on Tuesdays, Thursdays, and Saturdays. The process required cleaning with wound cleanser, patting dry, applying skin preparation around the wound, then covering with antibacterial dressing and foam.
When inspectors examined the resident's abdominal dressing at 1:25 p.m. on November 25, they found it dated November 20. The facility's own treatment records showed wound care documented as completed on November 22.
The Assistant Director of Nursing confirmed the discrepancy 11 minutes later. She verified the wound dressing was indeed dated November 20 and admitted "the wound treatment had not been completed on 11/22/25 as documented."
She promised to find someone to change the dressing.
The resident had been readmitted to Three Meadows on October 23 following an earlier stay that began September 10. Her diagnoses included pneumonia, anxiety, and surgical aftercare for digestive system surgery. Assessment records showed she had intact mental capacity.
Medical records revealed no documentation that the resident had refused wound care between November 21 and November 25. The facility's wound care policy, last revised in 2010, required staff to provide care per physician orders and document the date and time treatment was given.
The facility had identified five residents with surgical wounds at the time of the December 23 complaint inspection. Inspectors reviewed three cases and found failures in one.
The resident's experience illustrates a pattern she described to inspectors. Beyond the abdominal surgical wound, she said staff consistently failed to maintain her PICC line dressing without her repeated requests. PICC lines require careful maintenance to prevent dangerous infections that can enter the bloodstream.
The November 22 documentation showed nurses recorded completing wound care that never happened. The resident's dressing remained unchanged from November 20 through November 25, meaning her surgical site went five days without the cleaning, drying, and fresh antibacterial covering her doctor had ordered.
During those five days, the resident made at least one direct request for care on Saturday. The nurse who promised to return never did.
The Assistant Director of Nursing's admission that treatment records were falsified came only after inspectors discovered the dated dressing. Without the inspection, the resident's surgical wound might have continued going days between changes while staff documented care that wasn't provided.
For a resident recovering from digestive surgery with intact mental capacity, having to advocate repeatedly for basic wound care represents a fundamental failure of post-acute rehabilitation. The resident understood her needs and asked for help. Staff documented providing care they never delivered.
The inspection occurred following a complaint, suggesting someone reported concerns about care at the facility. The resident's experience with both her surgical wound and PICC line maintenance indicates the problems may extend beyond a single incident.
Her surgical wound remained unchanged for five days. She had to beg for the PICC line care that prevents life-threatening infections. And when she asked directly for help on Saturday, the nurse who promised to return simply didn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Meadows Post Acute from 2025-12-23 including all violations, facility responses, and corrective action plans.