The resident had irregularly shaped wounds on his right inner calf and scrape-like marks on his left upper leg, both scabbed over without any bandages or dressings. During interviews, he said he also had wounds on his right toes, right shin, left shin, and buttocks that he believed were one to two months old.
Photos from December 12 showed his right lower leg with closed scabs, bruising, and redness. His left lower leg showed similar injuries.
The facility's Wound Doctor had examined the resident on December 11 and written specific treatment orders for wounds on his right medial shin and left anterior shin. But those orders never made it into Pine Grove Manor's electronic medical records system.
The Director of Nursing admitted she was "unaware of any orders written from the provider because the desk nurse did not transcribe them into the electronical medical record."
Licensed Practical Nurse A, who was responsible for entering provider orders, gave conflicting accounts. She initially told inspectors that only she could enter orders and that the Wound Doctor "did not given any order(s) to place." But the Wound Doctor confirmed he had written treatment orders on December 11.
The resident's care plan contained no documentation about his wounds, despite their obvious presence during inspections.
The Wound Doctor told inspectors he "expects staff to follow all physician orders" and recommended that staff "administer the treatments as he ordered on 12/11/25."
Pine Grove Manor uses a two-nurse system during day shifts, with one handling clerical work and glucose checks while the other passes medications and performs wound treatments. The breakdown occurred in the handoff between the doctor's written orders and their entry into the facility's electronic system.
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.