Federal inspectors found nurses at Grove at Kirkwood repeatedly failed to document wound treatments and lacked basic medical supplies needed for proper care during a January complaint investigation.
Resident 123 suffered the skin tear to their left lower leg on January 22 when CNA ZZ was helping transfer them alongside Physical Therapist AA. The resident's leg got caught during the transfer, causing the wound.
A physician ordered daily wound care the same day: cleanse the skin tear with normal saline, apply xeroform dressing, and cover with dry gauze. The treatment was to be completed daily and as needed.
For five straight days, from January 22 through January 26, nursing staff failed to document completing any wound treatments in the resident's medical record.
When inspectors observed the resident on January 26, the dressing on their left leg still bore the original date of January 22 — four days old.
The facility's Assistant Director of Nursing gathered supplies from the treatment cart to change the dressing during the inspection. She discovered the facility had run out of collagen powder, a basic wound care supply needed for the resident's treatment.
After removing the old dressing, she found the anterior and lateral wounds appeared pink with serous drainage. The skin surrounding the wounds looked macerated — softened and broken down from moisture.
The nursing supervisor said she had observed the resident's wounds the previous week and thought the skin around the wound appeared more red than before. She completed the leg treatment without applying the required collagen powder because none was available.
Resident 123 was also missing compression stockings despite having an active physician order requiring them. The stockings help improve circulation and reduce swelling in patients with conditions like congestive heart failure, which the resident had been diagnosed with along with pneumonia, glaucoma, and diabetes.
The resident had been admitted to the facility on January 16, less than two weeks before the injury occurred. Inspectors found no baseline care plan in place to direct staff on the resident's specific care needs.
LPN KK told inspectors during interviews on January 28 and 29 that nurses were responsible for completing all treatments and dressing changes. The licensed practical nurse said residents should have compression stockings on when there's an active physician order.
The facility employed no dedicated treatment or wound care nurse. All wound treatments fell to the general nursing staff.
Director of Nurses C said during a January 29 interview that nurses were expected to follow physician orders and complete wound treatments as ordered. The nursing director expected staff to order supplies when they weren't available and to document treatments accurately in residents' medical records.
"Staff should not document a treatment as completed when it was not administered," the director of nurses told inspectors. The nursing supervisor also expected compression stockings to be placed on residents per physician orders.
The Regional Nurse Consultant confirmed that nurses were responsible for documenting completion of wound treatments in residents' electronic medical records and should follow physician orders for wound care completion.
The Assistant Director of Nursing acknowledged that accurate documentation was expected when treatments were completed, yet the facility's own records showed a five-day gap where no wound care was documented for a resident with an active skin tear.
The resident told inspectors on January 22 that they had a wound on their left leg and ankle. By January 26, when federal investigators observed the unchanged four-day-old dressing, the facility still lacked the basic supplies needed to provide the ordered treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove At Kirkwood, The from 2026-01-29 including all violations, facility responses, and corrective action plans.