MADISON, WI - Federal inspectors found that Belmont Nursing and Rehab Center failed to implement proper pressure injury prevention protocols, resulting in residents developing severe wounds that required emergency medical intervention.
Critical Care Failures Documented
The March 25, 2025 inspection revealed systematic failures in pressure injury prevention and treatment at the Madison facility. Two residents developed advanced stage pressure injuries due to inadequate care protocols and staff oversight failures.
The most serious case involved a resident identified as R25, who was at high risk for pressure injuries due to immobility and poor nutritional status. Despite these known risk factors, facility staff failed to implement aggressive prevention measures and did not follow physician orders for repositioning and wound care.
R25 developed an unstageable pressure injury on the sacrum on February 8, 2025. The wound progressively worsened over nearly a month due to inadequate treatment protocols. On March 6, 2025, R25 required emergency hospitalization where medical professionals assessed the wound as a stage IV pressure injury with active infection.
Breakdown in Basic Nursing Protocols
Federal surveyors observed multiple protocol violations during their inspection. Staff members were not wearing appropriate Personal Protective Equipment (PPE) when treating R25's wound, creating risk for contamination and infection spread.
A second resident, R65, also developed pressure injuries due to care failures. During a routine visit on March 3, 2025, a nurse practitioner discovered R65 had an unstageable pressure injury on the right lateral heel. Facility staff had not implemented proper offloading interventions to prevent this wound from developing.
Surveyors documented that nursing staff failed to identify, assess, and measure R65's pressure injury despite applying skin preparation treatments twice daily. The wound was observed uncovered and exposed to air, creating additional infection risk.
Staff Training and Oversight Deficiencies
The inspection revealed significant gaps in staff competency and supervision. A Certified Nursing Assistant reported that R65's wound dressing had been off for approximately 1.5 hours but failed to notify the supervising nurse, indicating breakdown in basic communication protocols.
R65 reported to surveyors that staff were not repositioning him every two hours as required by medical standards. The resident stated that staff had not provided information about risks and benefits of repositioning protocols, indicating failures in patient education and informed care.
Medical Standards for Pressure Injury Prevention
Pressure injuries develop when sustained pressure restricts blood flow to skin and underlying tissues. Stage IV pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle, representing the most severe category of these preventable wounds.
Medical protocols require repositioning immobile residents at least every two hours to redistribute pressure and maintain blood circulation. High-risk residents require additional interventions including specialized mattresses, heel protectors, and nutritional support.
When pressure injuries do develop, immediate assessment and measurement are critical for tracking healing progress. Wounds must be kept clean and properly dressed to prevent bacterial contamination that can lead to serious systemic infections.
Regulatory Requirements and Facility Obligations
Federal regulations require nursing facilities to demonstrate staff competencies necessary to prevent pressure injuries in residents whose clinical conditions make such wounds avoidable. Facilities must also provide appropriate treatment to promote healing and prevent complications when pressure injuries occur.
The facility's assessment indicated capability to care for residents with pressure injuries, yet the documented failures suggest inadequate implementation of established protocols. This discrepancy between stated capabilities and actual performance represents a significant compliance violation.
Impact on Resident Safety and Outcomes
Stage IV pressure injuries with infection require intensive medical intervention and significantly impact quality of life. These wounds can take months to heal and may never fully resolve, potentially leading to chronic pain and disability.
The hospitalization of R25 demonstrates how preventable care failures can escalate to medical emergencies requiring costly acute care interventions. Infected pressure injuries can progress to life-threatening sepsis if not promptly and appropriately treated.
Facility Response Requirements
The Centers for Medicare & Medicaid Services requires the facility to develop and implement corrective action plans addressing all identified deficiencies. These plans must include staff retraining, protocol updates, and enhanced monitoring systems.
The facility must demonstrate sustained compliance with pressure injury prevention standards through follow-up inspections and ongoing monitoring of resident outcomes. Failure to maintain compliance can result in additional sanctions including termination from Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belmont Nursing and Rehab Ctr from 2025-03-25 including all violations, facility responses, and corrective action plans.
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