Life Care Center of Skagit Valley: Wound Doc Failures - WA
By July 9, the wound had become a Stage II pressure ulcer.
The failure surfaced during a complaint inspection on September 4, 2025. What inspectors found was not a single missed entry but a sustained documentation gap that left a resident's deteriorating skin condition essentially invisible in the medical record for weeks.
The weekly skin checks told almost nothing. The entry from June 15 noted an open area in the sacral region with no further description. The checks from June 24, July 1, July 8, and July 15 were nearly identical, each logging an open area to the coccyx measuring 1.6 centimeters long and 3 centimeters wide. The measurements appeared, but nothing else, no tissue description, no wound bed characterization, no documentation of how the area was changing week to week.
The medical record contained no wound notes at all for June.
A wound care referral was initiated on June 25, prompted by a family request to the provider. The care plan reflected a pressure ulcer and listed the resident as being followed by a wound care clinic, also starting June 25. Then, two weeks later, the July 9 wound note confirmed what the sparse entries had failed to capture as it was progressing: a Stage II pressure ulcer.
In a joint interview at 3:30 in the afternoon on the day of the inspection, three staff members, identified in the report as Staff A, Staff B, and Staff C, sat down with inspectors. Staff C, whose role carried supervisory responsibility for documentation standards, acknowledged directly that the records were a problem. The expectation, Staff C said, was that any nurse who documented an open area would document it clearly and include measurements. That had not happened.
The explanation offered was that the nurse who completed the weekly skin checks was brand new and did not know how to document skin conditions correctly. Staff C said teaching had been completed with that specific nurse after the fact.
Staff C also pushed back on the timeline, arguing that Resident 9 had moisture-associated skin damage, with excoriated skin, but no actual wound or pressure ulcer until the July 9 documentation. The wound care referral on June 25, Staff C said, was a response to the family's request, not evidence that a pressure ulcer existed at that point.
Staff A added that the resident's family had a history of taking the resident to outside appointments without notifying facility staff.
Then Staff C said something that stood on its own: it was understandable, Staff C said, that the documentation related to Resident 9's skin was confusing and inaccurate.
That framing, that confusion and inaccuracy in wound documentation are understandable, sits at the center of what inspectors cited. The inspection referenced Washington state regulations governing nursing home care, and the harm level was recorded as minimal harm or potential for actual harm, affecting a small number of residents.
What the record shows is a resident whose family had to request a wound care referral themselves, whose skin condition was logged in the same vague language across five consecutive weeks, and whose medical record contained no wound notes for an entire month while the skin was, by the facility's own account, excoriated and open.
Whether the wound existed before July 9 or not, the documentation did not allow anyone reading the chart to know what was happening. A new nurse's learning curve became Resident 9's medical record.
The family had asked for a wound care referral. The facility said the documentation was confusing. Six weeks after the first notation of an open area, a formal wound note finally appeared, and it confirmed a Stage II pressure ulcer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Skagit Valley 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
LIFE CARE CENTER OF SKAGIT VALLEY in SEDRO WOOLLEY, WA was cited for violations during a health inspection on September 4, 2025.
By July 9, the wound had become a Stage II pressure ulcer.
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.