Charlottesville Health & Rehab: Wound Tracking Failures - VA
Then the paperwork started saying the wound didn't exist.
The resident, identified in inspection records only as R6, had a skin assessment completed upon admission that documented the stage three ulcer. A wound care company was engaged. Treatments were put in place. On paper, the facility was doing what it was supposed to do.
What happened next is what a federal inspection, completed September 4, captured.
Daily skilled assessment progress notes from January 31 through February 3, 2025, recorded the wound status as "No." Weekly skin assessments from February 7 and February 14 either repeated that finding or left out any mention of a stage three pressure ulcer entirely. The wound care company was treating a wound that nursing staff, in their own documentation, were simultaneously recording as not there.
A stage three pressure ulcer is not a minor skin irritation. It is a wound that has broken through the outer layers of skin and into the tissue beneath. They are painful. They are prone to infection. They require consistent, documented monitoring to catch deterioration before it becomes catastrophic. The entire clinical value of those daily notes and weekly assessments is that they create a record nurses and doctors can use to track whether a wound is healing, holding, or getting worse.
When those notes say "No," that record disappears.
On the morning of September 3, inspectors sat down with the facility's director of nursing and a nurse consultant identified in the report as administrative staff member AS #3. The nurse consultant pulled up R6's clinical record during the interview. She reviewed it. She agreed, according to the inspection report, that there were discrepancies between the skin assessments and the progress notes.
That was the extent of the facility's response on record. No explanation for how a stage three wound went undocumented across multiple assessments and nearly two weeks of daily notes. No account of whether anyone had caught the gap before inspectors arrived. No information was provided before the exit conference the following day.
The facility's own written policy required a licensed nurse to complete a skin observation tool detailing any wounds or skin impairments. The nurses completing R6's assessments were licensed nurses. The tool existed. The policy existed. The wound existed.
The documentation did not.
Pressure ulcer tracking failures are not a paperwork problem in the abstract. When a wound that is present gets recorded as absent, clinical staff making decisions about that resident's care are working from a false picture. A nurse reviewing notes before a shift may not know to look. A physician reviewing the chart may not know to ask. The wound care company arriving to treat the ulcer is operating in a separate lane from the nurses writing "No" in the daily notes, and nobody reading those notes would know the two realities were in conflict.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's assessment of what was documented, not a guarantee of what R6 experienced during those two weeks when the records said their wound was not there.
Charlottesville Health and Rehabilitation Center is a for-profit skilled nursing facility operating in Charlottesville, Virginia.
R6's wound, the one that the paperwork kept losing, had been there since admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charlottesville Health & Rehabilitation Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
CHARLOTTESVILLE HEALTH & REHABILITATION CENTER in CHARLOTTESVILLE, VA was cited for violations during a health inspection on September 4, 2025.
Then the paperwork started saying the wound didn't exist.
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.