LPN #233 examined the photographs during an August 19 interview and confidently identified Resident #60 by their orange shirt, bedside table, and window blinds visible in the images. The nurse recognized the wound dressing dated July 29 and could identify staff initials written on it.
But when asked about the classification of the wounds, LPN #233 maintained they were not pressure ulcers. The nurse stated that for the wounds to qualify as stage two pressure ulcers, "the wounds would have to be further down through the dermis."
The facility's own policy manual contradicted this assessment. Valley View's "Pressure Injury Staging Guide," dated 2016, defined a stage two pressure injury as "partial-thickness loss of skin with exposed dermis." The policy specified that the wound bed would be "viable, pink, or red, and moist" and that "adipose tissue would not be visible, and deeper tissues were not visible."
The photographs showed wounds matching these exact criteria.
LPN #233 told inspectors the wounds "blanched and were not pressure ulcers," apparently using a blanching test as the sole criterion for classification. The nurse said the wounds had appeared the same way since her first assessment on July 15.
Federal inspectors found this misclassification violated wound care standards that require proper identification and staging of pressure injuries. The facility's "Guidelines for General Wound and Skin Care" policy, dated May 10, 2017, required staff to "document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, peri wound tissue, and treatment of the wound weekly."
The policy also mandated that staff "notify the wound nurse/nurse supervisor for all new stage two to four pressure ulcers or with any questions."
By refusing to classify the wounds as pressure ulcers, the nursing staff potentially prevented proper notification protocols and specialized wound care interventions that stage two pressure injuries require.
The inspection revealed a fundamental gap between the facility's written policies and actual practice. While Valley View maintained detailed staging guidelines that clearly defined pressure injury characteristics, nursing staff applied different criteria in real-world assessments.
This disconnect had direct implications for Resident #60's care. Proper classification of pressure ulcers triggers specific treatment protocols, documentation requirements, and monitoring procedures designed to prevent deterioration and promote healing.
The misdiagnosis also affected the facility's compliance with federal regulations requiring accurate assessment and classification of resident conditions. Medicare and Medicaid reimbursement can depend on proper documentation of pressure ulcer stages and treatment.
LPN #233's insistence that the wounds needed to penetrate "further down through the dermis" to qualify as stage two ulcers directly contradicted the facility's staging guide. Stage two injuries are defined as partial-thickness skin loss with exposed dermis, not full-thickness wounds extending beyond the dermis.
The photographs provided clear evidence of the wound characteristics, including the dated dressing and recognizable room features that confirmed the resident's identity. Yet the nursing assessment failed to align with established clinical criteria.
Federal inspectors determined the violation resulted in "minimal harm or potential for actual harm" to residents, but the finding highlighted systemic issues with wound assessment and classification at the facility.
The case underscored broader concerns about nursing home staff training and adherence to clinical protocols. When frontline nurses cannot properly identify common conditions like pressure ulcers, residents may not receive appropriate interventions during critical early stages when treatment is most effective.
Valley View's wound care policies appeared comprehensive on paper, requiring detailed weekly documentation and supervisor notification for new pressure ulcers. But the inspection revealed these protocols only work when staff can accurately identify the conditions they're designed to address.
Resident #60 continued living with wounds that met the clinical definition of stage two pressure ulcers while receiving care based on an incorrect assessment that they weren't pressure ulcers at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Health Campus from 2025-08-22 including all violations, facility responses, and corrective action plans.