Delta Healthcare: Hospice Pressure Ulcer Goes Untreated - CA
The communication breakdown at Delta Healthcare & Wellness Center left facility nurses unaware that their resident had developed the painful wound, which exposes the dermis layer of skin and requires careful monitoring to prevent infection.
Resident 1 entered hospice care on May 16, when the hospice nurse documented finding "1 lower back pressure ulcer/injury, stage 2-partial thickness skin loss of exposed dermis, observable, most problematic pressure ulcer/injury." The hospice documentation detailed a specific treatment plan: cleanse with dermal wound spray, apply hydrogel medication, and cover with an Allevyn sacral dressing for extra padding, changing the dressing Mondays and Thursdays.
But Delta Healthcare staff knew nothing about it.
Licensed Vocational Nurse 1, who served as Resident 1's primary nurse when hospice care began, told inspectors that "hospice did not report that Resident 1 had stage 2 to her lower back." She said the hospice nurse should have reported the pressure ulcer discovery to facility staff.
The facility's own records confirm the gap. Resident 1's physician order summary from May 1 through May 31 contained no orders for treating a stage 2 pressure ulcer on the lower back. The treatment administration record for the same period showed no treatments given for such a wound.
Director of Nursing was unable to provide any documentation showing the facility had identified or treated the pressure ulcer. "Hospice did not report a stage 2 pressure ulcer to the nurse and the facility did not receive any treatment orders from the hospice nurse regarding a stage 2 pressure ulcer," the director told inspectors.
The breakdown violated the facility's own policy requiring collaboration between hospice and nursing home staff. Delta Healthcare's hospice care policy, dated January 1, 2012, explicitly states that "hospice and facility staff will collaborate on a regular basis concerning the resident's care" and that "nursing staff will be informed of any changes recommended by the hospice staff."
During a follow-up interview, the Director of Nursing acknowledged that "hospice was expected to communicate any skin issues identified to the nurse." She confirmed that discovering a stage 2 pressure ulcer "should have been reported to the nurse."
The policy also requires that hospice notes be included in facility progress notes, creating a paper trail that should prevent such oversights.
Stage 2 pressure ulcers represent partial thickness skin loss that exposes the dermis underneath. Without proper monitoring and coordinated care, these wounds can worsen into deeper, more serious injuries that penetrate fat, muscle, or even bone.
The hospice nurse's detailed treatment protocol suggests recognition of the ulcer's severity. The specified Allevyn sacral dressing provides extra padding specifically designed for pressure ulcers in the tailbone area, while hydrogel medication promotes healing in wounds with exposed tissue.
Federal inspectors discovered the communication failure three months later during a complaint investigation. The inspection found that while hospice was actively treating Resident 1's pressure ulcer throughout May, facility staff remained completely unaware of both the wound's existence and the ongoing treatment regimen.
This created a dangerous gap in care coordination. Nursing home staff responsible for repositioning residents, monitoring skin condition during daily care, and watching for signs of infection had no knowledge they needed to pay special attention to Resident 1's lower back.
The facility's hospice policy emphasizes that both organizations must "collaborate on a care plan for the resident," but the May records show no evidence such collaboration occurred regarding the pressure ulcer.
Inspectors classified the violation as having minimal harm or potential for actual harm, but noted the failure "had the potential for Resident 1's pressure ulcer to go untreated and worsen."
The case illustrates how communication breakdowns between healthcare providers can leave vulnerable residents caught in dangerous gaps. While hospice provided appropriate wound care, the nursing home staff who spent far more time with Resident 1 remained unaware they needed to incorporate pressure ulcer prevention and monitoring into their daily care routines.
Resident 1's wound, first identified by hospice on May 16, went unrecognized by facility staff for weeks while two separate medical teams unknowingly provided fragmented care to the same person.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Delta Healthcare & Wellness Center, Lp from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DELTA HEALTHCARE & WELLNESS CENTER, LP in VISALIA, CA was cited for violations during a health inspection on August 14, 2025.
But Delta Healthcare staff knew nothing about it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.