Federal inspectors found dirty, peeling dressings dated January 26 still attached to the woman's severe wounds on January 28, indicating no one had provided the daily wound care prescribed by her doctor.
The patient, admitted with paraplegia, pancreatic cancer, multiple stage 4 sacral pressure ulcers, and diabetes, required specialized wound treatment for chronic injuries covering her left hip, sacrum, left ischium, right buttocks, and right heel. Stage 4 pressure ulcers represent the most severe category, extending through skin and tissue to expose underlying muscle or bone.
During incontinence care on January 28, nursing assistants discovered the soiled dressings peeling away from stage 4 wounds on the woman's sacrum and left ischium. The dressings bore dates from two days earlier.
Licensed practical nurse V22 confirmed the breakdown during wound care later that morning. "The old dressing is soiled, dirty, and peeling off with date 1/26/26 indicates that nobody provides wound care yesterday," the nurse told inspectors.
The physician had ordered daily application of a specific debriding product after wound cleansing, followed by silicone super absorbent dressing. The product was designed to remove dead tissue from the wound bed, a critical step in preventing infection and promoting healing.
But V22 couldn't complete the treatment as prescribed. She told inspectors she was aware of the ordered product but "couldn't find it in the treatment cart" during the dressing change.
Instead, the nurse cleaned the wounds with saline, patted them dry, and applied medical honey and calcium alginate to the stage 4 sacral and ischium wounds. While these are legitimate wound care products, they were not what the physician had specifically ordered for this patient's complex injuries.
The wound care physician confirmed the significance of the missing treatment the following day. "R3 was admitted with those chronic wounds. I ordered (the product), which will debride the dead tissue from the wound bed," the doctor told inspectors. "The facility should have used the (the product as ordered) to change the wound dressing."
The facility's own wound care policy requires staff to "perform wound dressing changes as ordered by the physician using a clean technique on all chronic or contaminated wounds."
For patients with stage 4 pressure ulcers, consistent daily care becomes critical to prevent further tissue breakdown and infection. The wounds already extended through multiple layers of skin and tissue, making proper debridement and dressing changes essential for any hope of healing.
The patient's complex medical conditions made proper wound care even more crucial. Diabetes impairs the body's ability to heal wounds, while her cancer diagnosis and paraplegia created additional complications for recovery.
The inspection found that nursing staff had the knowledge to recognize the problem and the skill to provide alternative wound care, but lacked access to the specific products ordered by the treating physician. This gap between prescribed treatment and available supplies left a vulnerable patient with extensive wounds untreated for multiple days.
The failure occurred despite the facility having established policies requiring adherence to physician orders for wound care. The disconnect between policy and practice meant that even when staff identified the missing products, no immediate solution ensured the patient received her prescribed daily treatment.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, though stage 4 pressure ulcers left without proper daily care can rapidly deteriorate and become life-threatening.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Lawn Respiratory & Rehab from 2026-01-30 including all violations, facility responses, and corrective action plans.