The woman, admitted with pancreatic cancer and multiple severe pressure ulcers, was found with soiled dressings peeling off her stage 4 sacral and left ischium wounds during a January 28 inspection. The dressings were dated January 26, indicating no wound care had been provided for at least two days.
Federal inspectors observed two nursing assistants providing incontinence care to the patient at 10:50 AM. Her stage 4 wounds were covered with dirty dressings that were visibly peeling away from her body.
Thirty-five minutes later, a licensed practical nurse began wound care on the patient's multiple sacral wounds. The nurse told inspectors the old dressing was "soiled, dirty, and peeling off" and confirmed that nobody had provided wound care the previous day based on the January 26 date still visible on the dressings.
The nurse cleaned the wounds with saline, patted them dry, and applied medical honey and calcium alginate to the stage 4 sacral and stage 4 left ischium wounds. But she failed to follow the physician's specific orders.
According to the physician order sheet and treatment administration record, the wound care protocol required applying a specific product after cleansing, then covering with silicone super absorbent dressing daily and as needed.
The nurse told inspectors she knew about the ordered product but couldn't find it in the treatment cart to apply during the dressing change.
The wound care physician who treated the patient explained the critical nature of the missing product. He had ordered it specifically because it would debride dead tissue from the wound bed. The facility should have used the ordered product for all wound dressing changes, he said.
The patient had been admitted with severe medical conditions including paraplegia, pancreatic cancer, multiple stage 4 sacral pressure ulcers, and diabetes. Her mild cognitive impairment was documented in facility assessments.
A wound assessment by the physician documented the extent of her chronic wounds: stage 4 left hip, stage 4 sacral, stage 4 left ischium, stage 4 right buttocks, and stage 3 right heel.
Stage 4 pressure ulcers represent the most severe category of bedsores, extending through skin and tissue down to underlying muscle and bone. They pose serious risks of infection and can be life-threatening, particularly for patients with compromised immune systems from cancer.
The facility's own wound care policy requires performing dressing changes as ordered by physicians using clean technique on all chronic or contaminated wounds. The policy was presented to inspectors without a date.
Federal inspectors found the violations represented minimal harm or potential for actual harm to residents. The findings applied to one of three residents reviewed for wound treatment and care in a sample of eleven residents examined during the complaint investigation.
The inspection revealed a breakdown in basic wound care protocols at a facility treating some of the community's most vulnerable patients. When staff cannot locate ordered medical supplies or fail to follow physician instructions for wound care, patients with serious underlying conditions face increased risks of infection, delayed healing, and additional complications.
For the cancer patient with multiple stage 4 pressure ulcers, the missed wound care represented more than administrative oversight. Each day without proper treatment allows wounds to worsen and dead tissue to accumulate, potentially setting back healing progress and increasing her risk of serious complications.
The facility's inability to maintain adequate supplies of physician-ordered wound care products and ensure daily treatment protocols raises questions about medication management and care coordination for residents with complex medical needs.
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.