The resident told inspectors on December 18 that wounds on the right toes, right shin, left shin and buttocks were one to two months old. "A doctor prescribed medication nine days ago, but he/she has not received the medication," according to the inspection report.
Inspectors observed irregularly shaped wounds on the resident's right inner mid-calf with defined pink edges that were scabbed over. The left upper leg showed scrape-like marks that were also scabbed. Neither leg had bandages, dressings or protective socks.
The facility's wound doctor had examined the resident on December 11 and written treatment orders, but those orders were never added to the electronic medical system or medication administration record. The resident's care plan contained no documentation about the wounds.
Director of Nursing staff explained that the resident was out of the facility when the wound doctor made rounds on December 11. When the resident returned December 15, a skin assessment was completed, but the desk nurse responsible for entering all provider orders failed to transcribe the wound doctor's instructions.
"The DON was unaware of any orders written from the provider because the desk nurse did not transcribe them into the electronical medical record," inspectors wrote.
The wound doctor told inspectors he expected staff to follow all physician orders and recommended they administer the treatments he had ordered on December 11.
Licensed Practical Nurse A, who handles wound treatments on the day shift, said the only order entered was for the resident to be seen by the wound doctor again.
The facility operates with two nurses on day shift - one handling clerical work and glucose checks, the other passing medications and providing wound treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pine Grove Manor from 2025-12-22 including all violations, facility responses, and corrective action plans.